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DENTAL MEDICINE, 



AS CONNECTED WITH THE 



STUDY OF DENTAL SURGERY. 



PRACTICAL TREATISE 



DENTAL MEDICINE, 



A COMPENDIUM OF MEDICAL SCIENCE, 



AS CONNECTED 'WITH THE 



STUDY OF DENTAL SURGERY. 



ByTHOS. E. BOND, A.M., M.D., 

PROFESSOR OP SPECIAL PATHOLOGY AND THERAPEUTICS IN THE BALTIMORE COLLEGE 0> 
DENTAL SURGERY- 



THIRD EDITION, 

REVISED, CORRECTED AND ENLARGED. 




"H 



PHILADELPHIA: 
LINDSAY AND BLAKISTON. 

1863. 



/trsT.'r*- . 







' 






V-fc 1 * 



Entered according to Act of Congress, in the year 1862, 

By LINDSAY & BLAKISTON, 

In the Clerk's Office of the District Court for the Eastern District of Penn- 
sylvania. 



2-.iL- ty-.tL 



Wm. S. Young, Printer. 



PREFACE 



THE THIED EDITION 



The reception of this work has been more favora- 
ble than the author expected. It seems to have met 
a want of students of Dentistry. The author is fully 
aware of its imperfections, and knows that neither its 
plan nor execution will abide the test of critical exa- 
mination. But the book was prepared for a practical 
purpose, which it seems in some considerable degree to 
have subserved, and it is quite probable that such al- 
teration of its plan and increase of its volume as lite- 
rary taste or scientific requirement would demand 
might render it less useful to those for whom it was 
prepared. 

The author has therefore contented himself with 
such alterations and additions as he could make with- 
out' risk of impairing the usefulness of the work. 
They will be found to be considerable, and it is hoped 
beneficial — and with them it is respectfully submitted 
to the kind judgments of those, who, knowing the de- 
sign of the book, will comprehend the difficulty of 
preparing it, and be more disposed to consider its 
practical usefulness than its artistic imperfections. 

September 1, 1862. 



PREFACE 



The Baltimore College of Dental Surgery was or- 
ganized with the design of teaching Dentistry as a 
regular branch of Medicine, in which relation only, it 
can be regarded as a scientific pursuit, and the practice 
of it esteemed a profession. 

With this view it was arranged that the Faculty 
should consist equally of Dentists and practising Phy- 
sicians, and to the author of this treatise was intrusted 
the chair of Special Pathology and Therapeutics. 
Commencing the performance of his duties with no 
larger amount of knowledge of the subject than is 
commonly possessed by medical men, he has been led 
to discover much more importance in it than at first 
he could have supposed to exist. Endeavoring to 
avoid the very natural error of exaggerating the value 
of isolated facts or doubtful statements, upon matters, 
at once novel and from the circumstances peculiarly in- 
teresting, he has found that many things which at 
first he was disposed to regard as unlikely, are, never- 
theless, well attested and established facts; and, after 
mature investigation, he has become fully convinced 
that the relations of the teeth and their appendages 
with other, and even with vital parts, are sufficiently 



Vlll PEEFACE. 

important to be carefully studied both by the Dentist 
and Physician. 

After ten years' experience as a teacher of these sub- 
jects, he has found it absolutely necessary that a com- 
pendium of medicine should be furnished, in which 
should be brought together, in a small compass, such 
selected information as should meet the wants of the 
Dental Surgeon, and as none has been prepared by 
another he has reluctantly undertaken the task. 

The difficulty of performing it will readily be con- 
ceived, when it is observed how much was proper and 
how much was irrelevant: how cautious it was neces- 
sary, to be, that no needless matter should be intro- 
duced, and how careful that nothing pertinent should 
be omitted. 

Without the pretension of having done it well, the 
author is yet gratified that it has been done at all. 

Though particularly intended for the Dentist, the 
author flatters himself that he has presented the sub- 
ject in such a form as will render it deserving the at- 
tention of the general practitioner. 

It is not the custom of our profession to consider 
any thing unworthy of attention which has any bear- 
ing, however remote, upon the benevolent pursuit to 
which we have devoted our lives, but to the most fas- 
tidious it may be said, that subjects which have been 
thought worthy the attention of Hunter and Rush, 
may be investigated by all without fear of degrada- 
tion. 

THE AUTHOR. 



CONTENTS 



Introduction, 



PAGE. 

13 



CHAPTEK I. 



Preliminary Definitions, 



25 



CHAPTER II. 



Etiology, 

The Atmosphere, 
Heat and Cold, 
Malaria, 
Chemical Causes, 



29 
32 
33 
37 
39 



Symptoms of Disease, 
Progress of Disease, 



Diagnosis, 



CHAPTER III. 



CHAPTER IY. 



43 
44 



47 



CHAPTER V. 

Treatment of Disease, General Remarks on, . . 56 

Catalogue of Disease, ..... 59 

CHAPTER VI. 

Inflammation and its Consequences, ... . 61 

Inflammation, ...... 61 

Consequences of Inflammation, . . . . . 72 

Inflammation of the several parts composing the Mouth, and 

of the parts adjacent, . . . .83 

Inflammatory Fever, ..... 97 

Treatment of Inflammation, . . ... .99 

Caries, ....... 112 

Mortification, or Gangrene, . . . .114 



CONTENTS. 



CHAPTER VII. 

Ulcers, 
Local and Constitutional, 
Simple Purulent Ulcer, 
Simple Vitiated Ulcer, 
Callous Ulcer, 
Fungous Ulcer, 
Sinuous Ulcer, 
Carious Ulcer, 
Cancerous Ulcer,. 
Ulcers Dependent upon Constitutional Cause, 
Venereal or Syphilitic Ulcers, 
Scorbutic Ulcers, 
Scrofulous Ulcer, 



PAGE. 

121 
123 
123 
125 
126 
127 
128 
130 
131 
136 
136 
141 
143 



CHAPTER VIII. 

Tumors, . . . . . . . . 150 

Malignant — Osteo Sarcoma, .... 151 

Fungus Hsematodes, Bleeding Fungus, Spongoid Inflam- 
mation, Soft Cancer, Medullary Sarcoma, . . 152 
Polypus, ...... 152 

Benign Tumors, ...... 154 

Sarcomatous or Fleshy Tumors, .... 154 

Encysted Tumors, .... . 155 

Bony Tumors, ...... 156 

Exostosis of the Teeth, . . . . .159 

Tumors occasioned by Enlargement of Blood-Vessels, . 161 

Aneurismal Tumors, ..... 161 

CHAPTER IX. 

Diseases of the Teeth and Face dependent upon Morbid 

Conditions, either general or of other parts, 163 

Neuralgia, ....... 163 

Neuralgia Faciei, or Facial Neuralgia, . . . 163 

Intermittent Neuralgia, ..... 168 



CHAPTER X. 

Morbid Secretions of the Mouth, 



174 



CHAPTER XI. 

Morbid Effects of .Conditions of the Teeth, and the parts 
immediately connected with them, upon the ge- 



neral system, 



192 



CONTENTS. XI 



PAGE. 



CHAPTER XIL 

Morbid Effects of First Dentition, . . ; 195 



CHAPTER XIIL 

Sympathetic Diseases of Dentition, 

Cholera Infantum, 

Convulsions, 

Cutaneous Eruptions, . 
Intertrigo, . 
Crusta Lactea or Milk Crust, 
Strophulus, Tooth Rash, Red Gum, . 
Second Dentition, . 
Third Dentition, 



207 
209 
211 
212 
213 
214 
215 
216 
216 



CHAPTER XIY. 

Effects of Diseased Teeth and Gums upon the General 

Health, . . . . . .217 

Phthisis Pulmonalis, induced by Dental Irritation, . 241 

CHAPTER XT. 

Wounds of the Mouth and Face, .... 262 

Fractures, ...... 279 

Fractures of the Jaws, . 282 

Dislocations, or Luxations, . . . . 285 

Dislocations of the Lower Jaw, .... 286 

CHAPTER XYI. 

Particular Affections of the Mouth and adjacent parts, 288 

Diseases of the Gums, ..... 288 

Epulis, ....... 288 

Parulis, ...... 293 

Fistula of th?. Gum of the Lower Maxillary, having an Exte- 
rior Opening at the Hollow of the Chin, . . 296 
Spongy or Fungoid Inflammation of the Gums, . . 297 
Hemorrhage from the Gums, .... 299 

Inflammation of the Teeth, .... 301 

Absorption of the Sockets, ..... 308 

CHAPTER XYII. 

Diseases of tee Lips, ..... 312 

Hare-Lip, ....... 312 

Adhesion, ...... 317 

Contraction, . . . . ... 317 



Xll CONTENTS. 



CHAPTER XVIII. 

Diseases of the Gland-Ducts, .... 322 

Salivary Tumors, . . . . . . 322 

Tumors of the Submaxillary Gland, . . . 325 

Notes of the Operation, ..... 330 

Tumors of the Parotid Glands, .... 336 

Salivary Fistula, . . . . . .338 

CHAPTER XIX. 

Tumors requiring Amputation of a part or the whole of 

the Upper Jaw, ... . . . 341 

Amputation of the Lower Jaw, .... 344 

CHAPTER XX. 

Diseases of the Antrum, or Maxillary Sinus, . . 354 

Dropsy, or Retention of Mucus, . . . 355 

Inflammation, ...... 361 

Suppuration, ...... 362 

Caries, Necrosis, and other Morbid Conditions of the Bony 

Walls, 363 

Softening of the Bony Walls,- . . . . 370 

Exostosis, . ' . . . . . . 371 

Fistula of the Superior Maxillary Bone, . . 374 

Ozena, ....... 378 

Polypi and other Tumors, . . . . 379 

Insects in the Cavity, . . ... . 384 

CHAPTER XXI. 

Diseases of the Palate, . . . . 387 

CHAPTER XXII. 

Anesthesia, . . ... . . 400 



INTRODUCTION. 



The body of every animal is wisely contrived and per- 
fectly fitted for the purposes it is intended to subserve. 
Every part, however minute, is necessary to the complete 
performance of the work of the whole ; and a beautiful unity 
of purpose, and a necessary dependence of parts, are obser- 
vable throughout the organization. 

So remarkable is this unity, and so certain this dependence, 
that a naturalist, by examining a fragment of any one of the 
bones of an animal, may determine the character of the in- 
dividual it represents. Having ascertained the size, figure, 
&c, of any bone, he may infer, with infallible certainty, that 
every other part of the body to which it belonged was formed 
in perfect proportion to this part, and with strict reference 
to the purposes for which this particular portion was de- 
signed. Should a naturalist ascertain that a single bone 
presented to him was constructed for purposes of prey, he 
would immediately infer that a 1 beast so provided must have 
had strong muscles and bones of the neck and jaws, to ena- 
ble it to hold and tear the animals upon which it. was in- 
tended to subsist ; hind legs of such a formation as to enable 
it to spring upon its prey ; claws to seize and hold it, and a 
digestive apparatus suited to the reception and assimilation 
of the food thus procured. 



14 INTRODUCTION. 

The body of man must then be regarded as a unit, and 
though, for the convenience of description, we speak of its 
multitude of parts, it is a single organization, fed by one 
aliment, nourished by one blood, vitalized through one ner- 
vous system, directed to a common purpose, subject to one 
sovereign will, and pervaded by a general law of conti- 
nuance, decay and dissolution. 

As one part of the body is identified with all the others, 
it is necessary that a certain organic consent shall subsist 
between the several parts, in order that they may act in con- 
cert in carrying on the business of life. For instance, the 
eyes must act together; the muscles of the trunk must aid 
the muscles of the limbs, and many more agreements of mo- 
tion, infinitely complicated and astonishingly rapid, must 
subsist between different members of the body. 

The body has more to do than to perform certain acts by 
which it may be continued in being. It is, from its nature, 
liable, and from its condition exposed to injuries. It is con- 
tinually assailed by enemies from without and within. It 
has, therefore, certain signals of suffering, and is endowed 
with certain aptitudes, through which any part more par- 
ticularly attacked may receive succor from the rest. More- 
over, the parts being connected together by extension of 
common tissues, by blood-vessels and by nerves, the morbid 
conditions of one may readily be propagated to another. 
All this concert of parts, whether healthy or morbid, is 
called sympathy •* though, in the case of healthy action, im- 
properly so — and constitutes one of the most interesting and 
beautiful peculiarities of organized structures. 

In many instances the dependence of one part upon ano- 
ther is so direct, and the mode of communication so obvious, 
that there is no difficulty in detecting the process of sym- 

2uv, -with, 7ta&05, suffering — fellow-suffering. 



INTKODUCTION. 15 

pathetic action or suffering that may be observed between 
them. In other cases, this concert of action depends upon 
undiscovered links of union, and is known to exist only upon 
the evidence of common observation. Besides this sym- 
pathy of parts, there is a general interest of the whole organ- 
ism in the welfare of all its parts; and severe or long-conti- 
nued suffering in any one, however comparatively unimport- 
ant, will commonly induce a general derangement of health, 
and may involve the whole body in serious and even fatal 
disorder. 

Although in many cases no change in the structure of mor- 
bidly sympathizing parts might be discovered upon autopsic* 
observation, yet there is good reason to believe that sympathy 
is in fact a transfer or propagation of actual molecular change, 
and every physician knows that a disorder, primarily of 
little importance, may prove fatal by involving vital organs 
in a sympathy of disease. 

It cannot, therefore, be predicated of any organ, that its 
suffering is necessarily unimportant to the health of the 
whole system, since experience shows that the danger of al- 
most all disorders depends very much upon the sympathies 
likely to be established in the course of their progress, and 
that the importance of these sympathies is not always deter- 
mined by that of the organ originally involved. 

The facts above stated are universally admitted by the 
medical profession, and for the most part are recognised as 
important practical truths; so much so, that the study of 
particular parts as isolated from the rest, with a view to 
treat certain local affections as independent phenomena, has 
long since fallen into disuse, and every physician and sur- 
geon is expected to become conversant with all of medi- 
cine, as necessary to the proper care of any one of the or- 

* Avrog — w\p, one's own eye — actual sight of the parts of a dissected body. 



16 INTRODUCTION. 

gans of the body. An oculist, unless a thorough physician, 
would be utterly unqualified to treat diseases of the eye # 
The obstetrician must extend his knowledge far beyond the 
uterus, if he would claim a participation in the fellowship of 
medical science. 

Until very recently, however, the treatment of the diseases 
of the teeth seems to have been considered less a proper spe- 
cialty of medicine, than a mere mechanical craft, requiring in 
the operator little more than manual dexterity and physical 
force. Surgeons and physicians were generally profoundly 
ignorant of the importance of these organs to general health, 
and were contented to leave them to the care of any who 
were willing to take charge of them. Even now, dental dis- 
eases are rarely mentioned in the medical schools, and eminent 
professors of surgery have publicly confessed themselves in- 
competent to teach their students how to extract teeth. 

In the course of time, however, men of inquiring minds 
and studious habits, finding themselves in the practice of a 
rude and imperfect art, the deficiencies of which were con- 
tinually forced upon their observation, have been constrained 
to investigate the relations of the teeth to surrounding and 
distant parts. Well read medical men, waiving the general 
practice of the profession, have turned their attention to den- 
tistry, and of necessity have applied their previous informa- 
tion to the augmentation of dental pathology and therapeu- 
tics : and, finally, the management of the teeth has come to 
be an acknowledged specialty of medical science, and is ra- 
pidly advancing in public and professional consideration. 

It is thus that other departments of the healing art have 
gradually won their way to their present position and import- 
ance. Within a period comparatively recent, surgery in all 
its branches was regarded by physicians with sovereign con- 
tempt. Barbers were the operators, and mountebanks and 
old women dressed the sores. Midwifery was, if possible, 



INTBODUCTION. 17 

held to be more despicable, and even within a few years, an 
eminent body of scientific physicians have declared obstetrics 
to be unworthy the attention of a polite gentleman. 

It is necessary to say that surgery and obstetrics are now 
leading branches of the profession, and are zealously prac- 
tised by men of the first talents and greatest scientific and lite- 
rary acquirements. 

To our country belongs a large share of the honor of 
placing these two departments of medicine upon their pro- 
per level with other professional pursuits. 

The depressed condition of surgery and midwifery was 
the consequence of the vulgarity and ignorance of those who 
practised in those departments, and the bad reputation thus 
acquired was a formidable obstacle in the way of those who 
attempted to elevate them to the dignity of scientific pur- 
suits, but patient continuance in laborious and honorable ef- 
fort has eventually succeeded in accomplishing the desired 
result. 

The practice of dental surgery was long degraded, from 
causes precisely similar to those evil influences which so 
long depressed kindred branches of the art. Disregarded 
by educated men, it necessarily fell into the hands of the igno- 
rant and rude, and precisely as surgery and midwifery have 
gradually emerged from their barbarous state and attendant 
dispute, dentistry is now winning its way against all opposi- 
tion, to its proper consideration. It is a matter of honest 
pride, that our country is again foremost in this laudable 
work. 

The purpose of the present work is to treat of dental sur- 
gery as a distinct and proper specialty of medicine, and to 
present to the reader a digest of information, prepared with 
particular reference to the morbid connexions certainly ex- 
isting between the teeth and the rest x>f the body. 

These connections are far more important than is generally 
2 



18 INTRODUCTION, 

supposed by physicians or dentists. The reader of the fol- 
lowing pages will probably be surprised to find so great a 
variety of disorders treated of as directly or indirectly con- 
cerned in the production of pathological conditions observed 
in the mouth; and his surprise will, perhaps, be greater to 
find so many and so serious diseases of other organs traced 
to their primary seat in morbid conditions of the teeth. Yet 
the object of the author has been to condense this treatise as 
much as consistency would permit, and to admit nothing 
foreign to the subject properly under consideration. 

I have endeavored to present an elementary view of the 
disease, from which the dental student may acquire such a 
knowledge of common facts and general principles as may 
prove a guide in the application of special- art, and the foun- 
dation for the building up of such farther scientific acquisi- 
tions as experience and study may win from faithful profes- 
sional life. My purpose will have been in good measure at- 
tained, if perusal of these brief chapters shall awaken desire 
for more extended medical knowledge, and lure the dental 
student into the rich fields of learning, that lie all about the 
narrow and comparatively barren spot occupied by the spe- 
cialty of dental surgery. 



A TREATISE 



ON 



DENTAL MEDICINE. 



CHAPTER I. 

PRELIMINARY DEFINITIONS. 

The human body is liable to changes which more or less 
disturb the regular and healthful performance of the many 
functions* necessary to the completeness of its life, or in 
other words, to disease. These changes are commonly at- 
tended with alterations of the phenomena which experience 
authorizes us to regard as natural or normal, or in other 
words by symptoms^ which indicate the character and seat 
of the change which produces them. 

When parts thus diseased are inspected, we generally per- 
ceive alterations in their usual appearance and structure. 
Not unfrequently, however, the changes are too obscure to 
be detected by our present means of investigation. 

Many attempts have been made to define the essential na- 
ture of disease, but all have necessarily failed. It is impos- 
sible to frame with philosophical accuracy a definition of 
disturbed or altered conditions, unless we perfectly under- 

* By function is meant the particular part which each organ performs in 
the mechanism of life. The liver is an organ, its function is to secrete bile. 

f Symptoms are those observable differences from the healthy performance 
of function which lead us to suspect and often to detect disease. 

3 



26 PKELIMUSTAKY CONSIDEKATIONS. 

stand the nature of the organs ; and the mode of their acts. 
We cannot understand the ultimate cause of morbid pheno- 
mena, while ignorant of the essential nature of life itself, as 
manifested in the healthy performance of function. 

It is important to the student to know that medi- 
cal language does not pretend to the precision of abstract 
philosophical science. Medical definitions are not to be re- 
garded as accurately stating the nature of things, but sim- 
ply as descriptions which may serve for practical purposes. 
This fact has been forgotten by many eminent medical wri- 
ters, and their efforts to be absolutely accurate have often 
led to serious mistakes, and always to confusion of ideas and 
contradiction of facts. The study of essences belongs to me- 
taphysics, not to practical science, and having failed to reach 
any truth by analyzing mind, it will hardly prove success- 
ful in its attempts upon the body. 

We wish it then to be clearly understood, that medical 
terms are to be received in a conventional sense, and that, 
while they serve perfectly well to convey what knowledge 
we have of curative science, they will not bear the test of 
strict philosophical examination. For example, the word 
life, as used by medical writers, does not mean the essential 
vital principle, but the aggregate of the functions of the body ; 
not the ultimate cause which sets the machinery in motion, 
but its effect in the production of organic acts. Disease means 
all the morbid phenomena observed in a case, together with 
the structural changes upon which these phenomena depend, 
and any other more remote injury which may be concerned 
in their production. Thus a patient may complain of nau- 
sea; this sickness may be consequent upon defective diges- 
tion; the defective digestion upon interruption of the func- 
tion of the liver; the interruption of the hepatic* function 

* Hepar — the liver. 



PEELIMINAEY CONSIDERATIONS. 27 

upon change of structure in that organ; and that change of 
structure upon more minute pathological* conditions. Strict- 
ly speaking, we might regard all this train of evils as symp- 
toms merely of some obscure and inappreciable change which 
constitutes the disease. But in that case the Word would be 
of no practical use. This instance may suffice to illustrate 
our meaning, and the student may be saved much embar- 
rassment by keeping the fact thus presented always in his 
mind. Many false theories and much bad practice have re- 
sulted from attempts to philosophise in medicine. It is an 
experimental science, embodying the results of long experi- 
ence and protracted investigation. As such it is true, and 
worthy of all confidence. It is impossible to tell why any 
medicine produces -its effect — we do not understand the phi- 
losophy of it; but we know what effect it does produce, and 
that knowledge is sufficient, and infinitely more important. 

I will not trouble my readers with a recapitulation of the 
many definitions of disease proposed by eminent writers ; let 
it suffice to say that, accurate definition being impossible, 
all of them are improper ; and many of them strangely ab- 
surd. We can describe disease readily enough, but we cannot 
detect and exhibit its primary elements. Probably we would 
not be practically wiser if we could do so. 

Life, then, may be considered as the effects produced by 
organization. Health, the regular and orderly development 
of these effects. Disease, disorder and irregularity in their 
manifestation, or impediment to the accomplishment of one 
or more of them.f 

Physiology J has to do with the performance of healthy or 

* Pathological — ua&ug, suffering, koyog, discourse; that which relates to 
diseased conditions. 

fRoche and Sanson, Nouvenux Elements. 
J$U(xt?, nature, XoyOi, discourse. 



28 PRELIMINARY CONSIDERATION'S. 

natural acts, and physiological medicine or hygiene with the 
preservation of health. Pathology is the science of -diseased 
condi tions. Therapeutics* the art of applying remedies for the 
cure or relief of disease. Anatomy f is the study of the body 
as an organized machine. Surgery,J manual or mechanical 
medicine. Etiology, % the science of morbific causes. 

In the present treatise, it is our purpose to examine the 
etiology, pathology, and treatment of morbid conditions, 
with a general reference to practical dentistry. 

*@spa7Tsvio f I cure. 

f AvaTf^vw, I cut up. $x««(?> the hand, sQyov, work. $EtiJ, cause. 



CHAPTER II. 

ETIOLOGY. 

Causes of disease may be external or internal. By external 
causes we mean all those agents which are independent of 
our own organization, whether they produce their impres- 
sion upon the outward or interior parts of the body. Thus 
poison inhaled or swallowed, would be an external cause, 
though acting upon internal surfaces. 

By internal causes, we mean all such as are produced from 
our own organization ; as by the action of one part of the 
body upon another ; or by the connection and dependence 
.of parts ; or by the influence of the intelligence itself, which 
often embarrasses, and sometimes overwhelms the physical 
machine. 

By general causes, we mean such as affect simultaneously 
a large part of the corporeal system. By local, those which 
are very much circumscribed in their sphere of action. 
These terms like most others used in descriptive science, 
are not philosophically precise, since every cause must be 
supposed to act upon some structures to the exemption of 
others ; but they are sufficiently accurate to convey the mean- 
ing intended. It must not be supposed that general causes 
necessarily produce general diseases, and vice versa. A lo- 
cal cause, acting only upon a very small surface, may pro- 
duce universal disorder, while a general cause may beget a 
strictly lpcal disease. A plunge into cold water, drenching 
the whole surface, may produce nothing more serious than a 



30 ETIOLOGY. 

tooth-ache; while a prick of a finger may cause serious ge- 
neral disorder and even death. 

Further subdivisions of causes are based upon the charac- 
ter of the effects which they produce. Some' stimulate or in- 
crease the action of the blood-vessels; others debilitate or les- 
sen such action. Some act mechanically, dividing, tearing, 
bruising, &c.; others chemically, burning, corroding or de- 
composing. 

Predisposing causes are those which exert an influence 
sufficient to make parts more liable to disorder, without ac- 
tually disordering them. This term, again, is not absolutely 
accurate, for we cannot conceive of these causes acting in any 
other way than by producing disease, which doubtless they 
do, but in so feeble a degree as to give out no symptom of 
its existence. Exciting or efficient causes are those which im- 
mediately precede disorder, and are reasonably inferred to 
have induced it. It must not be supposed, however, that 
these divisions are absolutely descriptive of certain agents 
which permanently belong to either of them. A cause which- 
predisposes in one instance may excite in another, and vice 
versa. For example, a man may be exposed to intense cold, 
and while extremely chilled he may drink a large quantity 
of ardent spirits, and fever may ensue. In this instance, 
the cold would be regarded as predisposing and the alcohol 
exciting. On the other hand, a man may become intoxicated, 
and while thus enfeebled he may be exposed to cold, and fe- 
ver or inflammation might result. In this case, the alcohol 
and its effects would be the predisposing, the cold the exci- 
ting, cause. 

Some causes are utterly unknown, but are inferred to ex- 
ist as agents differing essentially from known causes, from 
A the peculiarity and uniformity of their effects. These are 
called specific. The causes of scarlet fever and of whooping 
cough are examples. 



ETIOLOGY. 31 

Almost every thing without and within us may, in some 
way or other, be productive of disorder to the human body. 
The air we breathe may carry into the inmost recesses of our 
system, invisible poisons, to hurt the lungs or spoil the blood ; 
it may withdraw our heat too rapidly, or it may fail to re- 
lieve us of our excess of caloric ; it may itself undergo chemi- 
cal changes which deteriorate its qualities, and render it more 
or less unfit for respiration. The food we eat may pain or 
sicken or convulse us. It may suddenly prostrate, or gra- 
dually destroy us. Water, even when pure, may irritate the 
disordered organs of digestion, and when impure, may carry 
unsuspected drugs into the stomach. Even the light of hea- 
ven may harm the delicate eye, and the sun's propitious heat 
exhaust the strength or inflame the brain ; while that all- 
pervading and powerful agent which we call electricity, en- 
tering our bodies at will, and playing upon our nerves at 
pleasure, may work in us fearful but inscrutable changes. 

'We are constantly exposed to the rude contact of bodies 
harder than our own, by which our tissues may be divided, 
broken, torn or penetrated; while other substances possess a 
mysterious power, to combine chemically with the elements 
which compose our bodies, and form of them new products, 
thus altering and disorganizing the parts subjected to their 
action. 

Nor are the enemies of health and life within us less active 
or efficient. The exquisitely organized body is continually 
undergoing change, and in all its parts a law is at work 
which impels the whole to decay and dissolution. Linked 
together by exquisite sympathies, traversed by numberless 
nerves and blood-vessels, performing most delicate and im- 
portant functions, and pervaded by a powerful moral intel- 
ligence, whose passions and appetites excite and depress the 
physical system to its utmost limits of endurance, the parts 



32 ETIOLOGY. 

of the body are continually liable to become diseased, and to 
radiate disorder throughout the whole. 

It will be impossible for me to introduce into the present 
work a full examination of each of the many causes of dis- 
ease which might be worthy of particular notice. I will only 
ask the attention of the reader to the consideration of such 
as are most important to us, as being concerned in the pro- 
duction of those diseases which the dental surgeon is expect- 
ed to treat. 

THE ATMOSPHERE * 

The air acts upon us in a variety of ways. By its pres- 
sure upon us it keeps us in form ; without that pressure the 
fluids coursing within us would overcome the resistance of- 
fered by the coats of their vessels, and universal turgescence, 
interruption of function, and death would ensue. 

It furnishes us with the oxygen necessary to preserve the 
vitality of the blood. Were the natural proportion of this 
element increased or diminished, we must suffer hurt. It is 
also the vehicle by which watery vapor acts upon our out- 
ward and inner surface, and the medium by which caloric 
or the matter of heat is brought into contact with us. It is 
therefore the means by which we feel those hygrometrical 
changes which have so much to do with our health, and the 
vicissitudes of temperature which, as morbific causes, are 
hardly less important. 

Increase in the density of the air has been supposed to 
produce serious epidemic affections. Persons who ascend 
high mountains generally suffer much from embarrassed re- 
spiration, and hemorrhages and pulmonary affections have 
been traced to changes in the mechanical action of the at- 
mosphere. 

* The atmosphere is composed of two great elements, called oxygen and 
nitrogen, with a small portion of carbonic acid. 



ETIOLOGY. 33 

Unless the supply of air be unequal to the want, the quan- 
tity of oxygen in the atmosphere has never been found defi- 
cient; but where persons have resided or been confined in 
crowded and ill-ventilated rooms, the most serious conse- 
quences have often resulted. When the deficiency of air is 
not so great as to produce rapid and violent results, the health 
often languishes, the complexion fades, the strength fails, and 
diseases of various kinds make life wretched, and shorten its 
duration. In the gorges of mountains are often found de- 
crepid, deformed, and even idiotic people, who bear sad tes- 
timony to the evil effects of depraved air. 

Heat and cold are universally recognized as having much 
to do with the causation of disease. Caloric or the matter 
of heat pervades all bodies, and constantly tends to an equi- 
librium. The animal heat which is elaborated by some ob- 
scure process, but little understood, obeys the common law of 
caloric, and constantly passes off to bodies less warm, or re- 
ceives increase from those more heated. Our sensations of 
heat and cold are therefore nothing more than indications of 
the loss and supply of caloric to our surface. When it passes 
off in greater quantity than we can supply it with com- 
fort to ourselves, we complain of cold ; when surrounding 
bodies draw less from us than we are in the habit of supply- 
ing, or communicate to us of their own excess beyond our 
wants, we feel heated. These variations in our state of ca- 
lorification are not limited in their effect to the production of 
certain sensations. They are capable of causing great dis- 
order in the performance of function, and creating morbid 
conditions of the most serious kind. 

Heat is an excitant ; cold must therefore be a depressing 
agent. Heat induces increased action of the heart and ar- 
teries; cold diminishes that action. 

But in considering the consequences of agents acting 
upon the human body, we must always remember that it is a 



34 ETIOLOGY. 

living machine, and is not merely passive under modeling 
influences. A thorn penetrating the substance of an inani- 
mate machine, would produce no other consequence than the 
mere perforation; but should it pierce the human body, it 
would induce a succession of phenomena, depending upon the 
vitality of the parts injured. Heat, acting upon a bar of iron, 
will expand it ; cold will contract it : acting upon the human 
body, heat will not only expand its tissues, it will excite the 
parts to increased action. Cold will not only contract the 
tissues, but lessen action. Further, heat, if long continued, 
will exhaust the vigor of the nervous and vascular system, 
and thus debilitate the whole frame; for it causes the or- 
gans to work more rapidly than usual— consequently to con- 
sume more of the means of action, while it adds nothing to 
those means. It does not increase the amount of blood, nor 
enrich its quality, but it causes it to be more rapidly circu- 
lated and consumed; it provides no additional nervous 
energy, but causes greater expenditure of it. In the course 
of such unusual consumption and expenditure, the parts ap- 
pear more than commonly vigorous, but the result must be 
that the supply of means soon falls below the usual consump- 
tion, and languor, depression or exhaustion results. Heat,* 
in other words, is an excitant or stimulant, and all agents 
of this class will enfeeble as a secondary and ultimate effect. 
Cold, being the opposite of heat, is of course depressing, as 
being the withdrawal of an excitant. But there is in the 
living body a recuperative power, which exerts itself power- 
fully to overcome morbid influences. This power we call re- 
action, and its chief phenomenon is increase of vascular ac- 

*It will be perceived that we use this word in the popular sense, as con- 
veying the idea of a certain sensation. When we speak of heat as an exter- 
nal agent, we of course mean the presence of caloric in a quantity so unusual 
as to create the sensation of heat. Caloric itself is absolutely necessary to 
life, and does not exhaust vitality when present in its normal or natural 
quantity. 



ETIOLOGY. 35 

tion up to and beyond the natural standard. When cold is 
suddenly applied to the body, the first effect is to lessen vas- 
cular action and nervous sensibility; but unless the applica- 
tion be very long continued, the circulation \vill soon resume 
its vigor, a glow of warmth will succeed to the chill, and per- 
haps the heart and arteries may work with a force and fre- 
quency incompatible with health. 

In order to explain certain pathological conditions, of very 
common occurrence in every part of the body, it is also im- 
portant to observe that when parts are suddenly chilled by the 
rapid abstraction of their natural heat, their nervous excitabi- 
lity, or the power of being impressed by agents, is increased* 
Every one has remarked the extreme sensibility of the fingers 
on a cold day, and dentists are well aware that delicate pa- 
tients cannot endure protracted and painful operations in the 
winter as patiently as in summer. 

To a man nearly frozen, it would be death often to bring 
him to a blazing fire. Frost bites are often strictly burns in- 
flicted at very low temperatures, upon parts unusually sus- 
ceptible through the abstraction of heat. 

If this be true of cold, the converse is true of heat Pro- 
tracted heat, as indeed the long action of all stimulants, wears 
out the excitability, and renders the body difficult to be im- 
pressed. Debility or weakness may be connected with both 
of these nervous conditions; hence weakness alone is not a 
characteristic of any disease ; it is merely a circumstance of 
it. A man half-starved would be very weak, and might be 
too much excited by a single glass of fermented liquor; an- 
other, exhausted by long continued intemperate drinking, 

*This is true in the case of the sudden diminution of any of the essential 
means of life. If food be withdrawn for a considerable time, the accumula- 
ted excitability of the system will make it dangerous to give the starving 
man an ordinary meal. If blood be abstracted, the whole system becomes 
more easy to be acted upon by food, medicines, &c. 



36 ETIOLOGY. 

might be equally debilitated, but could not be excited by im- 
mense quantities of distilled spirit. 

These remarks upon the effects of cold and heat will ena- 
ble us to understand the mode of production of many parti- 
cular affections through the agency of atmospheric changes. 

Excessive moisture in the air is also a common cause of 
disease, but only because the watery vapor withdraws our 
heat much more rapidly than dry air, at the same tempera- 
ture, would do. 

Air is also the vehicle through which aerial poisons of 
various kinds are brought to act upon us. 

We have mentioned specific causes, as the unknown agents 
which produce peculiar and uniform disorders. Some of 
these causes can only produce their effects through the air 
when it is highly charged with the poison ; others can act 
at great distances from their source, and apparently when 
much diluted by atmospheric mixture; and others have never 
been traced to any local origin, and while apparently poi- 
soning the air over immense spaces, produce no change in it 
which is appreciable to our nicest tests. 

Of the first class are the contagious , which may be propa- 
gated either by direct contact or by atmospheric infection 
within short distances : of the second are the causes of ende- 
mic diseases, and of the third are the inscrutable agents 
which produce those wide- spread disorders which we call 
epidemics.* 

The scope of our work does not include the causes of con- 

* Endemic, iv^rjfxog', Epidemic, evifrjftos. By endemics we mean diseases 
largely prevalent in a certain vicinity, and often traceable to a local cause, 
and always dependent upon such. An epidemic lias no positive connection 
with locality, and evidently does not spring from a local cause. The yellow 
fever is an example of an endemic ; cholera of an epidemic. Local causes, 
however, have much influence in giving efficiency to epidemic causes. Damp 
and foul air has been observed to give extraordinary activity to the cholera 
poison. But in such cases we cannot tell whether the result is due to in- 
crease of the active poison or decrease in the power to resist it. 



ETIOLOGY. 37 

tagions and epidemics ; but as certain endemic diseases fre~ 
quently exhibit themselves in the mouth and face, and very 
much embarrass the dentist who may unfortunately be igno- 
rant of their cause, nature and treatment, it is necessary for 
us to notice particularly the atmospheric vitiation which 
causes them. 

It has been observed, from time immemorial, that the bor- 
ders of sluggish streams and stagnant pools, and the vicinity 
of marshy grounds are unwholesome, and that persons who 
dwell in such places, or even remain there during a short time 
of certain seasons, are subject to peculiar disorders, not ob- 
served elsewhere, and evidently not produced from ordinary 
influences. To the causes of these diseases, which, though 
unknown in their nature, must be immediately connected 
with the peculiarities of the locations in which only they act, 
several names have been given, such as marsh miasma, ma- 
laria, and marsh poison. 

To this agent must be attributed by very far the greatest 
part of endemic diseases, and those which are most destruc- 
tive of health and fatal to life. The yellow fever of the West 
Indies and America, the plague of the Mediterranean coasts, 
the coast fever of Africa, the jungle fever of India, the remit- 
tent or bilious, and the intermittent or ague of many places, 
and many other affections which it is unnecessary to men- 
tion, are the productions of the poisonous emanations from 
wet soils. 

We have not as yet been able to discover the nature of 
marsh poisons. The most careful analysis of air selected 
from the pestiferous fens has not developed any alteration 
in the proportion of the elements of the atmosphere, nor any 
foreign matter whatever. Yet we have sufficient evidence 
to justify us in believing that the poison does act through 
the atmosphere, and, the failure to detect, only proves the 
inadequacy of our means of analysis. 



38 ETIOLOGY. 

Malaria is evolved during the day by the action of the sun 
upon wet ground containing dead vegetable matter. It as- 
cends with the watery vapor which is simultaneously disen- 
gaged, and commonly requires to be precipitated and con- 
centrated by the cold of evening before it exerts its ma- 
lign influence. Hence the popular dogma that summer dews 
are unwholesome ; an opinion based upon the experience of 
the fact just stated. The danger, however, is not from the 
dew, but from the concentrated malaria simultaneously pre- 
sent. In non-malarious regions, dews do no other harm than 
mere moisture may occasion. They never induce agues nor 
bilious fevers, dew owing its evil reputation altogether to 
being often found in bad company — an inference which purity 
escapes, even more rarely than it does contamination. 

There are cogent reasons for supposing that the cause of 
the endemics in question is not one and the same for all of 
the distinct disorders belonging to the category of malarious 
diseases, but that each has its separate and peculiar poison, 
though all are the product of vegetable decomposition under 
the combined operation of heat and moisture. It would be 
incompatible with the design of the present work to discuss 
this and other interesting questions connected with these 
wide-spread and destructive emanations. The subject, how- 
ever, is well worthy of the careful attention of every man, 
and especially of every student of medical science. Igno- 
rance of facts connected with this subject which might be 
learned in a few hours, annually causes the death of many, 
who unnecessarily expose themselves to the assaults of fatal 
pestilence. 

The only known prophylactics'" against malaria are the 
intervention of thick woods between the source of the poison 
and the house, and the rarification of the evening air of the 
dwelling by fires. 

* Ilpo<pvlu$is, — prophylaxis, from 7rpoyvX'j.<r<ra) — I guard against. 



ETIOLOG-Y. 39 

It is not necessary to particularise the mechanical and 
chemical canses which may injure the human body gene- 
rally, nor would it be consistent with our purpose to examine 
in detail the effects of ailments, occupation, &c, in the occa- 
sional production of disease. These considerations belong 
to general hygiene, and if introduced here, would swell our 
work to an inconvenient size. We shall, therefore, only 
allude to those matters as we may have occasion in the prog- 
ress of our discussions. 

In organs endowed with a high degree of vitality, the laws 
of chemical affinity are ordinarily inoperative, being subor- 
dinate, to an inexplicable and all-controlling law of life. 
This, however, is only true within certain limits, for some 
chemical agents will always enter into combination with the 
animal tissues, whether living or dead, when brought into 
contact with them. 

The enamel, and even the bony structure of the teeth, are 
acted upon very readily by many acids, both vegetable and 
mineral, which combine with the earthy base, lime, and form 
new compounds with it, breaking up, of course, the integrity 
of the organ. The enamel is a crystalline mineral substance, 
and possesses no"vital organization ; consequently it is quite 
as liable to be acted upon by chemical agents while in its 
normal place, as it would be when separated from. the body. 
It is therefore easily perceived that this external defence 
of the tooth may be very readily penetrated, and the ivory 
of the organ laid open to the action of alimentary matters 
and fluids of the mouth. 

It is from this cause that what is called caries results. 
Unfortunately the word is used to express an affection of 
the bones entirely different from the peculiar disorganiza- 
tion called caries of the teeth. The former is a modified vital 
process, analogous to ulceration of the soft parts, the latter 



40 ETIOLOGY. 

is a chemical erosion. Dr. Westcott has published* the 
results of some interesting experiments made by him for the 
purpose of testing the activity of certain chemical agents 
upon the teeth. The mode of these experiments was as fol- 
lows: 

A water bath was prepared, kept constantly at 98° by a 
spirit lamp, and regulated by a thermometer. In these were 
placed vials containing the substances to be tested. In each 
of these was placed a human tooth — care being taken to 
select those of as similar organization as possible, and whose 
enamel was perfect. 

A hundred articles, such as are most commonly used as 
food, condiments or medicine, were thus tested, and uncom- 
mon care was taken to watch the progress of the chemical 
action upon the teeth, subjected to such application. 

The results of these experiments are summed up by Dr. 
Westcott in the following propositions : 

1st. Both vegetable and mineral acids act readily upon 
the bone and enamel of the teeth. 

2d. Alkalies do not act upon the enamel of the teeth. The 
caustic potash will readily destroy the bone by uniting with 
its animal matter. 

3d. Salts, whose acids have a stronger affinity for the lime 
of the tooth than for the base with which they are combined, 
are decomposed, the acids acting upon the teeth. 

4th. Vegetable substances have no effect upon the teeth 
until after fermentation takes place, but all of them capable 
of acetic fermentation, act readily after this acid is formed. 

5th. Animal substances, even while in a state of putre- 
faction, act very tardily, if at all, upon either bone or enamel. 
On examining the teeth subjected to such influence, the 
twentieth day after the experiment, no visible phenomena 
were presented, except a slight deposit upon the surface of a 

* Vide Amer. Journal of Dental Science, Sept. 1843. 



ETIOLOGY. 41 

greenish slimy matter, somewhat resembling the green tartar 
often found upon teeth in the mouth. 

Acetic and citric acid so corroded the enamel in forty- 
eight hours, that much of it was easily removed with the 
finger nail. Acetic acid or common vinegar is not only in 
common use as a condiment, but is formed in the mouth 
whenever substances liable to fermentation are suffered to re- 
main about the teeth for any considerable length of time. 

Citric acid, or lemon juice, though less frequently brought 
into contact with the teeth, acts upon them yet more readily. 

Malic acid, or the acid of apples, in its concentrated state, 
also acts promptly upon the teeth. 

Muriatic, sulphuric, and nitric acid, though largely dilu- 
ted, soon decompose the teeth. These are in common use 
as tonics.* 

Sulphuric and nitric ethers have a similar deleterious ef- 
fect: these are used frequently as diffusible stimulants, The 
acids of some of the salts also corrode the teeth. Super tar- 
trate of potash, or cream of tartar, destroys the enamel very 
readily. This article is frequently used to form an acidulated 
beverage. (It is also the basis of certain popular dentifrices, 
which whiten the teeth by corroding their surfaces.) Rai- 
sins so corroded the enamel in twenty -four hours that its 
surface presented the appearance and consistency of chalk. 

Sugar had lo effect until it had undergone acetous fermen- 
tation. 

In fact, the combination of the elements composing the 
enamel is one readily broken up by the application of the 
most common acids, and were it not for the natural alkali- 
nity of the healthy saliva which neutralizes free acids in the 
mouth, the ravages of caries would be even greater than they 
are. As it is, the devastation is frightful, and yet its cause 

* Tonics are medicines which invigorate the system. 

4 



42 ETIOLOGY. 

is not fully ascertained. Some persons are naturally sub- 
ject to the disease, inheriting either peculiarity of dental 
structure or of salivary secretion, which defy all efforts to 
arrest the ravages cf caries. Their teeth begin to corrode al- 
most as soon as they are protruded, while the teeth of others 
lie in apparently unfavorable saliva, and with little sanitary 
attention, and prove absolutely impregnable. The liability 
to caries, for some reason or other, is very general and very 
great, and the subject deserves much more thorough investi- 
gation than it has yet received. 



CHAPTER III. 

SYMPTOMS AND PKOGRESS OF DISEASE. 

All changes of normal phenomena observed to attend dis- 
eases are called symptoms. Sometimes we know nothing 
more of the disease than that it causes certain appearances, 
and in fact we are commonly compelled to regard the symp- 
toms as the evils to be combated, and to rely mainly upon 
experience for the proper means of relief. The skill of the 
.physician and surgeon is chiefly exercised in interpreting 
these signs correctly and pursuing their indications to the 
desirable result. 

Sometimes a case will present but a single symptom, as 
pain in a tooth ; at other times, while one particular symp- 
tom indicates the seat and nature of the primary malady, a 
number of secondary and collateral signs will claim attention 
and clamor for relief, and again all the morbid appearances 
may be so general and vague as to afford no satisfaction as 
to the nature and seat of the disease. 

Local symptoms are those which present themselves in the 
very seat of the disease ; sympathetic, such as are manifested 
in other organs than that primarily affected, and which are 
dependent upon the distant disease, being due to their rela- 
tions with it through the brain, spinal marrow, and sympa- 
thetic nerves. General symptoms are such as affect a large 
part of the body simultaneously. 

Generally speaking, the local symptoms are the most impor- 
tant, as they indicate the seat of the disease upon the extent 
and intensity of which the suffering of the sympathizing or- 
gans depends. It is always exceedingly important to detect 
these local symptoms, and deduce from them correct know- 



44 SYMPTOMS OF DISEASE. 

ledge of the pathological condition they represent. But this 
is often a matter of great difficulty, as the greater intensity 
and obtrusiveness of sympathetic symptoms may deceive us, 
and we may readily mistake them for local symptoms. 

Sympathetic symptoms are worthy of careful attention, 
for though caused by distant disorders, yet they manifest real 
disturbance in the organs to which they belong. And it of- 
ten happens that these sympathizing organs suddenly assume 
diseased conditions of the most alarming character. The 
judicious physician will watch them carefully, especially if 
the brain be the seat of them. 

General symptoms are those manifested by the heart and 
arteries, and the nervous system, which, acting throughout 
the whole system, when disordered, give out everywhere 
signs of distress. 

PROGRESS OF DISEASE. 

A disease is said to be continuous when its prominent symp- 
toms are not interrupted by any law of the disorder, from 
the commencement to the end of it. We have an instance 
of this in continued fever. 

We use the term intermittent to distinguish a very impor- 
tant class of disorders, characterized by regular periodical 
disappearance and return of symptoms. Such are agues. 

Remittents are those diseases which present, as a character- 
istic symptom, a periodical abatement of intensity, very ma- 
nifest, though not amounting to intermission. The bilious 
fever of our country belongs to this class. 

Diseases are said to be acute when they run their course 
rapidly; Chronic* when they occupy a comparatively long 
time in their progress. 

The student must not suppose that the term acute, neces- 
sarily implies violence or intensity. It is true that violent 
disorders are commonly of brief continuance, but it does not 

* Xpovoc — time. 



PEOGEESS OF DISEASE. 45 

follow that all diseases of brief continuance must be severe. 
Neither is it true that chronic diseases are less serious than 
those which are more rapid, for the reverse is very frequently 
the case. The terms acute and chronic have reference to 
duration, and not to intensity. 

As a general rule, all diseases abate their severity early in 
the morning and increase it in the evening. This increase 
is called an exacerbation; if very severe, a paroxysm. This 
last term has a peculiar meaning when applied to intermit- 
tents. 

The phenomenon of intermission is one of the most curious 
and inexplicable of all observed by the physician. The dis- 
eases characterized by this peculiarity consist of an indefinite 
number of attacks or paroxysms, each of which, after having 
exhibited a succession of conditions, disappears, leaving 
no symptom of disease, except the exhaustion of the patient 
be considered such. After a certain time of intermission or 
exemption, another attack is sustained, and so the disease 
progresses by alternate paroxysms and departures. Each 
paroxysm consists of a chill or cold stage, a fever or hot 
stage, and a sweating stage in which the fever disappears and 
the intermission commences. 

If there be a paroxysm in every twenty-four hours, the 
disease is called a quotidian ;* if it occur on alternate days, a 
tertian, f if there be two days of intermission, a quartan,^ &c. 

Sometimes there will be two paroxysms a day, or a dou- 
ble quotidian; sometimes two paroxysms on alternate days, 
double tertian ; or the double tertian may consist in the daily 
occurrence of a paroxysm, at hours coinciding ou the alter- 
nate days. Many other modifications of periodicity occur in 
the disease, but the intermission is distinct in all. The quo- 
tidian and tertian are by far the most common forms of ague. 

* Quotidian — quotidies, daily. f Tertian — tertius, third. 

% Quartan— quartus, fourth. 



46 PROGRESS OF DISEASE. 

It not unfrequently happens that the paroxysms occur 
regularly, but do not prevent the ordinary succession of 
chill, fever and sweat, but merely cause excessive pain in 
some sensitive part, usually occupying but little space. This 
pain obeys the law of intermission and periodicity as other 
forms of paroxysms do, and is known as intermittent neu- 
ralgia.* It is very important that the dentist should be well 
acquainted with this form of disease, as it frequently occurs 
in the teeth and parts about the jaws, &c, and may be easily 
confounded with tooth-ache from local causes; a mistake 
which has caused the infliction of much unnecessary pain and 
the loss of valuable teeth. 

Remittent diseases are characterized by a remarkable di- 
urnal abatement of their symptoms, not amounting to inter- 
mission, but apparently analogous to it. Some of the most 
fatal diseases which afflict the human family are of that class. 
For example, yellow and bilious fever. Abatement, however, 
is common to all diseases, as none maintain absolute unifor- 
mity of symptoms throughout their course. Remission is, 
however, a very marked and unnatural abatement, and is 
periodical as to the time of its occurrence. It is not an ac- 
cident , but a phenomenon, of disease, not really an abate- 
ment, but only a defect of truthful manifestation. 

Certain diseases always present the same symptoms, and 
in the same order, and perseveringly run through them all 
unchecked by treatment, or the circumstances of age, sex, 
constitution, &c, which powerfully control other diseases. 
The small pox, measles, hooping-cough, &c, are examples of 
this class. They arise from specific causes, and are some- 
times called specific diseases, though this term includes other 
diseases of an entirely different character. 

* Neuralgia, from vtvpos, neuros, a nerve, and alyo<;, algos, pain. 



CHAPTEE IV. 



DIAGNOSIS. 



Diagnosis* The art of following symptoms to their pro- 
per pathological cause and ascertaining the character, loca- 
tion, and extent of disease, of which they are the signs. This, 
of course, involves the discrimination of one kind of disorder 
from all others, and is often extremely difficult, sometimes 
impossible. When one or more local symptoms are promi- 
nent beyond others, we may sometimes ascertain at once the 
seat of the disease, but even in such cases we must not de- 
cide until we shall have ascertained whether these local symp- 
toms are primary or sympathetic; an inquiry which often 
requires much general knowledge of disease, and. a capacity 
for close consecutive reasoning. 

When our attention is first called to a patient, we often 
encounter a great number of symptoms of different kinds, 
proceeding from various organs, and all calling for relief. 
In the midst of this general outcry, the attentive observer 
will generally detect one voice of distress more earnest than 
the rest, and directing his inquiry to the part thus desig- 
nated, he frequently comes at once upon the cause of the 
general trouble. The local signs are always the most im- 
portant, and withal, often the most obscure. The first thing 
to be done, then, in the conduct of diagnosis, is to ascertain 
whether there are any local signs ; next, to discover whether 
any or all of them are sympathetic, and if so, of what primary 
affection ; and lastly, to consider whether the general and sym- 

* Lia yivua-Ko. I know through, or thoroughly. 



48 DIAGNOSIS. 

pathetic symptoms corroborate our suspicions ; that is, whe- 
ther they can all be accounted for upon the supposition that we 
have found the local cause, and whether any are absent which 
are uniformly or commonly concurrent with similar condi- 
tions to those supposed to exist. Sometimes we arrive at a 
strong probability as to the place of primary disease by a 
process of exclusion. Taking up all the viscera, tissues, &c., 
that could possibly be implicated, we decide that one and an- 
other are sound, and finally are left to suppose that one of 
whose soundness there is no such certainty, is the organ in 
fault. 

In the process of investigation, we use all means of exami- 
nation that reason and experience may suggest. "We ascer- 
tain whether the function of the part be well or ill performed, 
— whether its sensibility be increased or diminished, — whe- 
ther its appearance be changed, — whether organs known to 
sympathize with it are suffering. We inquire into the pro- 
bability of this or that organ being diseased from the habits 
of ancestry, and previous history of the patient. When the 
eye can be used, we examine the part carefully to note 
change of size or color or relation to adjoining parts. When 
it can be handled, we use the touch, to ascertain whether the 
part be altered in form or density or position. Great delicacy 
of touch may be acquired by long and careful practice in this 
kind of investigation, and it should be assiduously cultivated 
by Dental, as it is by general surgeons. Deposits of matter 
can be detected by the finger of one examiner, which would 
entirely escape the notice or confuse the diagnosis of another ; 
and this difference of diagnostic skill will show itself in many 
other cases of comparison. 

It sometimes happens that diagnosis will detect disease in 
two or more organs simultaneously, or complication. 

It would of course be impossible for any man to conduct a 
diagnosis properly upon any case of disease, unless he should 



DIAGNOSIS. 49 

be acquainted with diseased conditions generally, and parti- 
cularly with the relations and sympathies of parts. The den- 
tal surgeon is not prepared to investigate symptoms occur- 
ring in the mouth, until he can detect those which are sym- 
pathetic, and trace them to their source. Were he guided only 
by a prominent local symptom, he might make serious mis- 
takes. For instance, a female may complain of violent pain 
in a tooth, which may in fact be entirely due to sympathetic 
connexion with the uterus, and not at all dependent upon any 
diseased condition of the tooth in which it occurs. 

The mode of distinguishing dental diseases and those of the 
parts adjacent to the teeth and mouth is fully set forth in 
works of dental surgery. We will, therefore, omit any par- 
ticular directions upon this subject; but we would earnestly 
urge upon every dentist to extend his knowledge until it 
shall embrace at least an elementary knowledge of the entire 
subject of diseases and their cure. 

Independently of the necessity of diagnosing the local affec- 
tions, it is always important to ascertain those conditions 
which are immediately represented by general symptoms: 
or more correctly, it is always important to ascertain how far 
the nervous centres and vascular system are participating in 
a disorder. A number of symptoms, very variable and dif- 
ficult to be described, announce general nervous sympathy 
and the degree in which it exists, but the connexion of the 
vascular system with a diseased state, is, for the most part, 
determined by the pulse* that is, by the beating of the arteries 
due to the propulsion of blood through them. 

The artery which is generally examined for this purpose, 
is the radial, which is of sufficient size, and passing near the 
surface at the wrist, is most conveniently situated for exami- 
nation. 

The frequency, quickness, force or resistance, volume, and 

* Pulsus.— Lat. 



50 DIAGNOSIS. 

any peculiar sensations given by the pulsation, are all sub- 
jects for observation, and contribute to the discovery of the 
nature, seat, and degree of disease. 

Since the days of Galen, judicious and successful physicians 
have paid much attention to the pulse as a guide to correct 
diagnosis and practice, and although it is too common in this 
day to hear this symptom decried as uncertain, yet the fact is, 
that to those who know how to interpret its communications, 
it furnishes the most valuable of all our means of diagnosis. 

In order to understand the morbid pulse, it is necessary to 
be well acquainted with its healthy conditions, for it is only 
by comparing its pulsations with the natural standard that 
we are able to detect morbid variations. 

The pulse differs in frequency at different periods of life. 
In infancy it is much more frequent than in mature life, and 
becomes slower in old age. In infants* under two years of 
age, the number of pulsations is above one hundred in a 
minute; in adult age, about seventy, and somewhat less in 
advanced life. These numbers, however, are susceptible of 
great variation. Whylt mentions a case where a healthy 
woman had a pulse of one hundred and twenty ; and instances 
have been known where the natural pulse has amounted to 
only thirty-six or forty. The pulse of females is usually 
somewhat more frequent than that of men, and owing to the 
nervous sensibility of the gentler sex, is more readily excited 
by mental emotions, &c. 

The healthy pulse is accelerated by exercise and mental 
excitement. It is more frequent in the evening than in the 
morning, after a full meal, or the use of exciting drinks, and 
in pregnancy. It is also often very much accelerated after 
copious evacuations and under circumstances of great pros- 
tration. It is diminished by the horizontal posture, by rest, 

* Some writers, as Billardand Valleix assert that the pulse of young infants 
is not near so frequent as is generally supposed. See Chomel, General 
Pathology, p. 171. 



DIAGNOSIS. 51 

by moderate bleeding, and by the influence of certain drugs, 
such as digitalis and the tartrate of antimony. 

Indeed, the frequency of the pulse is subject in so great a 
degree to the control of idiosyncrasy* and accident, that no 
positive inferences can be drawn from this solitary symptom, 
unless the habitual pulse of the patient be known. Chomel 
says, "I have seen a lady whose pulse during the paroxysms 
of intermittent fever did not beat above sixty per minute, to 
the great astonishment of her physician. This astonishment 
would have ceased had he counted the number of pulsations 
during the intermission, these being not above forty per mi- 
nute." Quickness and frequency are not synonymous terms. 
Frequency has reference to the number of pulsations in a 
given time, as a minute ; quickness to the time required for 
the completion of a single pulsation. Slowness is opposed to 
frequency, not to, quickness* Thus we may have a slow quick 
pulse; that is, one in which the beats in a minute are fewer 
than natural, but each particular beat is rapidly performed. 
For an opposite to quick; physicians frequently use sluggish 
or laboring. 

The natural pulse is soft or compressible ; that is, it readily 
yields to gentle pressure with the finger. The hard pulse is 
the reverse, offering considerable resistance to the obliteration 
of its channel by pressure. Tense, wiry, firm, &c, are used 
to express modifications of hardness. 

Differences are also observed in the volume or size of the 
pulse. Sometimes it is full and open, at other times, small and 
contracted. It is called regular when the beats succeed one 
another in natural order; irregular or interrupted, when the 
regular succession is broken by omissions of pulsation. 

Certain conditions, too, are attended with peculiarities of 
the pulse. In aneurism of the heart, or large arteries, it im- 
parts a peculiar thrilling sensation to the hand, which has more 
aptly than is usual in such illustrations, been compared to 

* Idiosyncrasy — idiot duyxpatrte — peculiar constitution. 



52 DIAGNOSIS. 

the sensation which would be imparted by the passage of a 
fluid through, a shattered quill. Ossification of the coats of 
the arteries destroys their elasticity; and of course renders 
the pulse very hard. The hard pulse is usually attended by 
a peculiar condition of the blood, which when drawn and co- 
agulated, presents a yellowish, lymphy surface, which is called 
the buffy coat ; with but few exceptions, a very important 
sign of inflammatory action .* The following precepts for 
feeling the pulse, though very minute, are nevertheless wor- 
thy the attention of those who are inexperienced in it. Long 
habit imparts to the fingers an extraordinary accuracy of sen- 
sation in this respect ; but until it shall be acquired, it is not 
easy to form correct conclusions without all the care demand- 
ed by these rules. 

The physician should wait until the patient has recovered 
from the emotion produced by his presence, requesting him 
to preserve absolute silence, and to remain in the sitting or 
horizontal posture. The pulse may be examined at the tem- 
ples, lateral parts of the neck, arm, thigh, wrist, and wher- 
ever the arteries are sufficiently large and superficial ; but 
the radial artery is generally preferred at the place where it 
ceases to be covered by the muscles of the forearm, opposite 
the radio-carpal articulation. If the patient be up, he should 
be placed in the sitting posture, if in bed, he should be upon 
his back, so that he may neither incline to the right nor left, 
and thus impede the circulation of blood in the arteries. 
The arm should be placed nearly in a state of extension, and 
sustained in its whole length, so that the muscles may be re- 
laxed. The forearm should be nearly prone, that it may, upon 
the cubital edge and the radial edge, be a little raised. Care 
should be taken that no bandage or clothing impede the flow 
of blood in the axilla, at the elbow or any other point. All 
bandages should be removed so that there be the least possi- 

* The buffy coat is also seen upon the blood drawn from pregnant females. 



DIAGNOSIS. 53 

ble compression. By means of these various precautions, we 
may be certain that there is no foreign obstacle to the flow of 
blood through this vessel. 

The artery of the left side should be felt by the right hand, 
and vice versa ; the four fingers placed parallel on the same 
line, should be applied over the track of this vessel ; the in- 
dex finger should be nearest the hand of the patient, and the 
little finger applied lightly, should be the first to receive the 
impulse of the blood ; at the same time that the four fingers 
are placed over the radial artery, the thumb, or rather the 
palm of the hand, should rest upon the dorsal face of the fore- 
arm, thus affording solid support to the fingers by which the 
pulse is examined. The latter should at first receive a slight 
lateral movement in order to ascertain the situation of the ves- 
sel. When the fingers are all placed upon the artery, the 
pressure should be gradually increased and diminished seve- 
ral times in succession, so as to appreciate the influence of the 
pressure upon it, and thus more easily ascertain its different 
qualities. Twenty or thirty successive pulsations should in 
this manner be examined. It is not without advantage to ex- 
amine the pulse in the two arms alternately, or at once ; it 
should also, in particular cases, be examined in other places 
wherever it may throw light upon the diagnosis. It may be 
also examined several times, or at least a second time, before 
leaving the patient. However minute these precepts may ap- 
pear, they cannot be neglected without inconvenience. — Cho- 
mel, Elem. General Path. 

The inferences of pathological conditions to be drawn from 
the several above mentioned differences of the pulse, will be 
explained, as far as the purpose of this treatise requires, when 
we come to treat of particular diseases. 

Pain is one of the most common and important symptoms 
of disease. It is this which usually gives the first intimation 
of disorder, and drives the patient to medicine for relief. It 



54 DIAGNOSIS. 

is very important that the physician and surgeon should know 
how to interpret this sign, and in order to this, much general 
knowledge of parts and symptoms is necessary. 

An uninstructed observer naturally infers that the pain is 
always felt in the part diseased, and that its intensity accu- 
rately represents the degree of the disorder. 

But such prima facie opinions are often very erroneous. 
We have already remarked that a part may sympathize with 
a local disease seated in a distant and dissimilar organ. It 
also happens frequently, that diseases of the nervous centres 
and of the nerves themselves, occasion pain at the extremities 
of these organs of sensation, instead of at the point actually 
attacked. Violent pain in the nerves of the face may depend 
upon disease located in the brain or intermediate parts ; and 
similar conditions are noticed in other nerves. 

Nor does the degree of pain represent necessarily the de- 
gree of the disease which causes it. Some parts are much 
more sensitive than others, the most important organs being 
least sensitive. The quality of sensation does not necessarily 
belong to living bodies, but is distributed to the several parts, 
arbitrarily, yet with wonderful wisdom and mercy. Pain is 
intended to warn us of danger and compel us to preserve the 
integrity of the body ; it is therefore set as a sentinel chiefly 
upon the outposts of life : the external surfaces being much 
more sensitive than others; those most carefully protected 
being least profusely endowed with this watchful property. 
Hence it happens that the brain, heart, and lungs may be 
very seriously diseased without causing much, or indeed any 
local pain, while an unimportant injury to the eye or skin 
will create great distress. 

The nature of the disease may often be guessed from the 
character of the pain, as it is burning, scalding, fixed, fugi- 
tive, darting, throbbing, &c. As pain does not point out with 
certainty the seat of the disease, and as its intensity does not 



DIAGNOSIS. 55 

necessarily indicate the degree of the change producing it, 
neither does its abatement or disappearance prove the relief 
or cure of the disorder. In many instances it certainly does 
so, hut very often it does not. 

Pain may be lulled by the action of causes which lessen the 
sensibility, as by narcotic medicines ; by the exhaustion inci- 
dent to protracted sufferings, by morbid conditions of the 
nervous centres, or the nerves themselves; or by absolute 
loss of vitality. It sometimes happens that the sudden ces- 
sation of violent pain is a most fatal symptom, as showing 
that mortification has occurred in the diseased part. 

Pain is often intermittent, and disappears only in obedience 
to a law of disease, not of health. 

The importance of the symptom depends not upon the 
question of absolute suffering, but upon the cause of it. A 
temporary whitlow often occasions much more severe suffer- 
ing than a fatal disease. Spasmodic pain, occasioned by vio- 
lent irregular muscular contraction, is, as a general thing, not 
nearly so serious as the continued and increasing pain of in- 
flammation. Neuralgic pain, the most severe, is the least 
alarming of all. The severity is due to the seat, not the de- 
gree of disease. It requires experience and judgment to dis- 
. tinguish the pain of spasm from that of inflammation. Com- 
monly the pain and the sensitiveness to pressure enable us 
to determine th"> question. In inflammation, the vascular 
system is more inclined, and the part is sensitive, often ex- 
quisitely so, to pressure. Spasm is less likely to be attended 
with high arterial action, and the seat of it is often gratified 
rather than distressed by pressure. These distinctions, how- 
ever, are not always to be relied on. It is often very dim- 
cult to distinguish spasm of the womb from inflammation of 
the organ and its appendages ; and even colic is sometimes 
attended with inflammatory symptoms — more or less compli- 
cation of spasm and inflammation existing. 



CHAPTEE V. 

GENERAL REMARKS ON THE TREATMENT OF DISEASE. 

The first step towards the cure of disease is to remove the 
cause which has produced it. Unless this can be done, we must 
be very much embarrassed in our efforts to relieve, inasmuch 
as the morbid conditions are continually liable to renewal. 
The impracticability of doing this effectually, forms the most 
serious obstacle to the successful treatment of many disorders. 
Children teething during very hot weather are subject to the 
action of combined causes, which often induce diseases which 
are very serious and very difficult to be controlled, while 
the causes continue to act. Dead teeth remaining in the 
mouth may provoke a series of unpleasant and even danger- 
ous evils, which cannot be removed while the cause of them 
remains. 

It must not be supposed, however, that the removal of the 
primary cause of the disease will necessarily procure the sub- 
sidence of the disease itself. If a man pierce his flesh with a 
thorn, the wound will remain and may give great pain after 
the foreign body has been extracted ; the effects of a wound 
from a bayonet or musket ball may manifest themselves in 
serious and fatal disease long after the instruments of the in- 
jury have been withdrawn. The same truth holds good in 
all kinds of injuries by whatever class of agents they may be 
produced. 

The absolute rest of a diseased part, when the nature of 
its function permits, and the least possible exertion of others, 
is very conducive to cure. 



TREATMENT OF DISEASE. 57 

There are, however, certain exceptions to this rule. Certain 
mordid conditions of the articulations are improved by exer- 
cise ; a particular mode of ocular affection requires the light, 
&c. ; — but the exceptions are few and the rule general. 

The regimen of the patient, that is his diet, clothing, exer- 
cise, employment, &c, require judicious management. 

Finally, the most important part of treatment consists in 
the skilful application of therapeutical agents, and surgical 
means ; but of this part of the subject we will treat particu- 
larly when considering special diseases. 

The natural idea of remedies is, that to each disease there 
is an antidote or direct curative, and that good practice con- 
sists in so distinguishing the one as to be able to prescribe 
the other. Nothing can be more untrue. We have few me- 
dicines that even seem to antagonize disease directly, and 
those, no doubt, act mediately, as other medicaments do. 
These few medicines we call specifics. They are drugs, the 
administration of which is often followed by the disappear- 
ance of certain well-marked disorders, the nature of which is 
very obscure. The practice of prescribing medicines which 
act mysteriously to cure disease is called empirical. It may 
be, nevertheless, good and scientific practice. But it is only 
in a few instances that empirical practice is justified by long 
and sure experience. Any system of medicine that is based 
upon the principle of antidotes or antagonism, is radically 
wrong, and must be practically destructive of health and life. 
The human body is not a machine, consisting of isolated parts 
related to each other only by position, and capable of being 
separately altered, repaired, or renovated. Nor is disease an 
abstract thing, to be dealt with directly and overcome by 
force applied to its own hurtful quality. The human body 
is an exceedingly complicated organism, whose aggregate ef- 
forts constitute one life. The nature of the organs and of' 
5 



58 TREATMENT OF DISEASE. 

their life is incomprehensible. Disease is, when appreciable 
to us, only a modification in the structure or function of an 
inscrutable organ, attended by more or less embarrassment 
in the work of other organs and inconvenience to the whole 
life. By certain means we have the power to exalt, depress, 
and modify the vital activity of parts, and our reason and ob- 
servation teach us that in the use of these means we may aid 
very materially in the effort at restoration which nature con- 
tinues to make until life is extinguished. The treatment of 
disease consists in thus aiding nature, and requires the exer- 
cise of the most general knowledge, the closest observation, 
the purest reason and the quickest intelligence. There is no 
employment in which the practitioner should rely more on 
himself and less on his means. Medicine, is the most purely 
intellectual of the professions. The knowledge of the powers 
of medicines is a remembrance of facts acquired in the long 
experience of mankind, especially of men, professionally as 
well as naturally qualified, to make observations on the phe- 
nomena of the life of the human body, as they have been de- 
veloped under the presence of substances not ordinarily used 
upon it. The use of these medicines requires much more 
than a recollection of the circumstances under which they 
have been used before, and the apparent results of their use. 
It requires a capacity, derived from various sources, to de- 
termine whether medicines ordinarily followed by given re- 
sults are likely to be useful in a present case, differing more 
or less from all others. No two diseased conditions are found 
to be exactly alike. Though nature admits of boundless re- 
semblances, she positively forbids u 



59 



CATALOGUE OF DISEASE. 

Many of the morbid alterations which seem to constitute 
disease, or to cause symptoms, have been observed upon the 
living and the dead subject: many others have as yet escaped 
detection. We are unable, therefore, to compose a full list 
of these different conditions of parts, but those which are of 
common occurrence, and are well ascertained, may be de- 
scribed as follows : 

1. Eedness, swelling, and loss of cohesion of tissues. This 
is the most common of all modes of alteration, and is the cause 
of a large part of the disorganizations observed in the body ; 
it is called inflammation* The local symptoms of this con- 
dition are heat, redness, swelling, pain, and diminished, al- 
tered or suspended function. The general symptoms arejpy- 
rexia, or fever, of a particular type, seemingly connected with 
altered state of the blood. 

2. Stuffing or engorgement of the veins, or congestion. 
The symptoms are not so well defined as in the first kind. of 
affection. The local suffering is generally much less, though 
when certain organs, such as the brain and heart, are the seat 
of congestion, the pain and discomfort are often very consi- 
derable. The function of the congested organ is greatly em- 
barrassed, or altogether suspended. The general symptoms 
are commonly such as mark diminished action. 

3. Eed indurations ; vegetations; fungi, polypi. 

4. Vesicles, pustules, suppuration, erosion, ulceration, per- 
foration, gangrene. 

* Ilvg, fire — from the burning sensation and heated appearance of patients 
in fever. 

(5)* 



60 CATALOGUE OF DISEASE. 

5. Thickening, granulations, thickness of tissues naturally 
transparent, adhesions, effusions of serum, false membranes. 

6. Conversion of one tissue into another. 

7. Gray induration, gelatinous degeneration, tubercles, en- 
cephaloid matter, cancerous matter. 

8. Contraction, dilatation and complete obliteration of na- 
tural canals. 

9. Accidental canals, fistulas, accidental tissues, cysts. 

10. Development of gas in cavities. 

11. Living bodies in organs. 

12. Effusions of blood, collections of blood. 

14. Chalky, stony, hairy, horny, and melanotic* produc- 
tions. 

15. Changes of form and relation, wounds, ulcers, disten- 
tion, lacerations, ruptures, fractures and dislocations. 

16. Foreign bodies. 

17. Vices of formation/)* 

The fluids of the body, especially the blood, are doubtless 
capable of undergoing change primarily, and communicating 
distress and disease to other parts. But the pathology of the 
fluids is but very little understood. The same may be said of 
the nervous matter, of the nature of which we know nothing. 

The above catalogue is therefore very defective, as it takes 
no notice of some of the most common and most important 
of all diseases, such as fever ; and describes as diseases, con- 
ditions which are only incidental to other, previous, and more 
important phenomena. Nevertheless, it is as accurate, or 
nearly so, as the present state of medical science will permit. 

It is my purpose to select from this list such pathological 
conditions as are particularly connected with the pursuits of 
the dentist, omitting none, which, even in a remote degree, 
concern him, and passing by those in which he has no pro- 
fessional interest. 

* MiXoc— black. f Roche & Sanson, Path. Med. Chir. 



CHAPTEE YI. 

INFLAMMATION" AND ITS CONSEQUENCES. 

The most common, and by far the most important of all 
morbid conditions, is one, the prominent characteristics of 
which are pain, redness, swelling and heat. This is called 
Inflammation, and may occur in any part, naturally possess- 
ing sensibility. 

It is an unusual, though, we cannot say always perverted, 
condition of the vessels and blood of the parts concerned ; at- 
tended with alteration or suspension of its natural function 
often accompanied with entirely new vital acts, through which 
tissues are destroyed and reconstructed, vessels perforated or 
permanently closed, and devastation or renovation of the so- 
lids procured. It is the great destroyer and preserver of the 
body, or rather it accompanies the extraordinary vital con- 
ditions through which organization is broken up or preserved, 
and often seems as inseparable from the one as the other* 
Hence it has been called "Nature's Surgeon," though but for 
it, surgeons and physicians would have little to do. Cer- 
tainly a degree of inflammation is often inseparable from re- 
cuperative processes, and though we may imagine the process 
to be present, without the attendant inconvenience, we are 
obliged to submit to the union, and invite inflammation to do 
what neither knife nor ligature can accomplish. From this 
fact, considerable confusion has arisen among medical philoso- 
phers as to the terms which should be used in speaking of 
inflammation ; but practically, there is little perplexity about 



62 INFLAMMATION AND ITS CONSEQUENCES. 

the matter. The student of disease soon learns to distinguish 
the inflammatory condition that is likely to end well or ill? 
and to know whether he should interfere to abate or exalt 
the process. In surgery, inflammation is often not only tole- 
rable but desirable — in Medicine, it is almost always a thing 
to be dreaded, prevented, and abated — but even in Medicine 
there are a few occasions when the physician watches for the 
active inflammatory process, as the mariner on a dangerous 
coast watches for the light of day. Inflammation is, in fact, 
a very comprehensive term, applied to a great variety of 
conditions in which local vascular activity and deranged cir- 
culation are prominent features. The influx of healthful 
blood freighted with reconstructive flbrine — that comes to 
repair a sudden breach of continuity, and with little distur- 
bance of surrounding sensibilities, deposits its precious lymph 
between the gaping lips of the wound — is attendant with red 
turgescence and is called inflammation. The more copious 
flow that distends unruptured vessels and forces through their 
coats a serous exudation, is called inflammation. Should 
lymph be thrown out, and a mixed tumor be formed, and a new 
product be created amidst burning and throbbing and gene- 
ral distress, we call the process inflammation. And should 
local ruin ensue, and the blood dissolve and tissues break up 
and chemical laws assert their dominion, we say that inflam- 
mation has done it all. 

Nevertheless there is no essential difference between what 
has been called "healthy and unhealthy inflammation." There 
are circumstances under which the most unexceptionable 
character and quality of inflammation proves fatal — and any 
quality of it may rapidly change and become unhealthy by 
a modification of the action of the diseased condition, — not 
reaching to a change in the essential nature of the disease — 
" Healthy inflammation " is nothing more than such an inflamed 
condition as, under the circumstances, is likely to end well 



INFLAMMATION AND ITS CONSEQUENCES. 63 

— "its healthfullness" is not in itself, but in its circumstances. 
An abscess on the surface, and containing perfect pus, an- 
nouncing certain cure, would be a very "healthful" affair, 
but a similar one in the liver would be a very "unhealthful" 
tumor ; or the same superficial abscess, without ceasing to be 
inflammatory, might suddenly throw out a very unhealthy 
pus, or cease to provide any, and put on appearances indica- 
tive of destruction. 

Certain appearances give reason to believe that the inflam- 
mation is proceeding towards cure. While these exist, we 
call the inflammation " healthful." 

The process of inflammation, supposing a case to go regu- 
larly through what may be presumed to be its natural stages, 
is as follows: 

The exciting cause being applied, (whether it be immedi- 
ately exciting or depressing, is of no consequence, inasmuch 
as high action may ensue upon either provocation) blood is 
sent through the part with augmented velocity. The cause 
of this is no doubt due to modification of the nervous sensi- 
bility of the part, but the manner in which this acts is in- 
scrutable. The capillaries and minute arteries are distended. 
This may arise from the fact of their being naturally diluted 
under a certain degree of irritation, as is evident from the 
reddening of the skin by friction and the phenomenon of 
blushing ; or from their mechanical distention under increased 
pressure. Capillaries which previously contained but single 
files of the red corpuscles, now admit of them rolling through 
in masses ; and these come crowding in. Y essels. naturally 
invisible, are visible now, shooting over clear white spaces 
like lines of fire. A burning pain, modified by the sensibi- 
lity of the part concerned, accompanies this stage of inflam- 
mation, and the function of the organ is seriously impaired 
in proportion to the extent of it involved. The eye, for in- 
stance, is rendered useless from a moderate degree of super- 



64 INFLAMMATION AND ITS CONSEQUENCES. 

ficial inflammation. As dilatation increases, the blood is 
checked in its progress through the distended vessels ; more 
sluggish turgescence ensues, and the thinner part of the blood 
transudes, and the parts adjacent become more or less dis- 
tended with extravasated serum, or with the "liquor san- 
guinis." 

This condition may amount to little more than healthful 
excitement ; the vessels being a little too full, and tending to 
throw off some of their fluid contents ; or it may amount to 
serious obstruction in the circulation. 

The condition may remain for a brief period and then sub- 
side, or may advance to a more vigorous stage of inflamma- 
tion ; or it may become persistent or chronic, the sensibility 
becoming accustomed to the new condition, the pain disap- 
pearing and slow modifications of function or constituent or- 
ganization resulting. Inflammation increasing, there is ex- 
tension of the excitement to the arterial trunks that supply 
the part. More blood and of altered character is sent to the 
inflamed spot. The capillaries no longer maintain their vi- 
tal elasticity; they enlarge like mere material tubes under 
the severe pressure. The circulation moves heavily through 
the part ; "the red corpuscles are no longer limited to the cen- 
tral current, but encroach more and more on the lateral and 
clear " lymph spaces." Exudation is more copious than in 
the previous stage, and of a different kind. It consists chiefly 
of " liquor sanguinis," and this is altered from the healthy 
standard. The fibrin is increased, not only in quantity, but 
also in plasticity, or tendency to become organized."* 

Some of the small vessels very commonly give way and 
permit the altered blood to flow out. The fibrine is diffused 
among the tissues. Even that which is regularly supplied 
becomes excessive from the arrest of formative power in the 

* Miller's Surgery. 



INFLAMMATION AND ITS CONSEQUENCES. 65 

disordered part, and tends to form new structures to be 
changed into an excretive substance — a fact that plays an im- 
portant part in the immediate and remote consequences of 
inflammation. The state of things is thus summed up by the 
author already quoted: — 

"The over-distention of the capillaries is established; the 
capillary power is, for a time, gone ; perhaps in consequence 
of diminution or actual suspension of their nervous influence, 
and the coats of the capillaries and other vessels are spongy, 
softened, and impaired in cohesion, being themselves the sub- 
jects of structural change. The languor of circulation ap- 
proaches stagnation, and at some points this has actually oc- 
curred ; every part of the distended capillaries is occupied by 
crowded colored and colorless corpuscles . . . Altered liquor 
sanguinis is exuded in profusion. The attenuated and soft- 
ened capillaries also give way in their coats, and from the 
lesion blood is extravasated in mass. Suppuration is in pro- 
gress by extra- vascular degeneration of the fibrinous exuda- 
tion, or as some suppose, by a secretive elaboration of it ere 
yet it has left the vessel. The parenchyma, infiltrated by li- 
quor sanguinis, pus, and blood, softens and is broken up, and 
the disintegrated texture becomes mixed with the escaped 
contents of the vessels. The formative power has ceased, and 
the opposite condition, a tendency to disintegration from di- 
minution of vitality, has become established. Disorder of 
function is complete. Secretion for example, being in the 
first place arrested, and, when restored, more vitiated than 
before. In the circulation of the part truly inflamed all is 
sluggishness and stagnation, but that of the parts around is 
unusually active. The arterial trunks in the vicinity con- 
tinue to play with increased energy ; blood continues to be 
sent, but cannot now be transmitted in its direct course. In 
the inflamed parts it meets an obstruction, and being sent 
round another way, it throws a stress on the collateral ves- 



W INFLAMMATION AND ITS CONSEQUENCES. 

sels; tliese ; however, retain vigour sufficient for the aug- 
mented labor and pass the current briskly round." 

"While the apparatus of deposit is thus unusually busy, 
that of absorption is in abeyance. During inflammation, the 
lymphatic and- minute veins do little or nothing as absor- 
bents." 

The regular sensible progress of inflammation may then 
be said to be from a condition of morbid excitation, attended 
with simple serous effusion through a higher grade of disor- 
der, attended with exudation of plastic, flbrine and liquor san- 
guinis; altered condition of the blood; feeble capillary ac- 
tion; and more complete arrest of function, to the ultimate 
stage of inflammation, a condition in which there is extrava- 
sation of blood, destruction of texture and formation of pus, 
of more or less perfect quality. 

Mr. Miller shows very clearly that something like this is 
a natural gradation of inflammation, by pointing to familiar 
examples, where we constantly observe the several conditions 
in the natural relation to others of comparative distance from 
a common centre. In a common abscess we find the cen- 
tral portion broken up, and the seat of suppuration soft 
and fluctuating. Beyond this is a less prominent and 
harder portion marking where the inflammation has been of 
less active grade, and only caused fibrous effusion ; and exte- 
rior to this a soft cedematous circle where serous effusion has 
relieved the smaller vessels. 

When the suppurative or destructive condition has been 
reached, inflammation may be said to be at an end, and we 
have to deal with its consequences. 

But one of these consequences is inflammation of tissues 
adjoining those thus greatly impaired, and so — as we rarely 
lose sight of inflammation in the treatment of the case — we 
are in the habit of regarding the results above described as 
terminations or natural conclusions of, or incidents to inflam- 
mation. It matters little, however, what we call them. 



INFLAMMATION AND ITS CONSEQUENCES. 67 

Pain is a very characteristic symptom of inflammation. It 
commonly begins with the formation of the disordered con- 
dition, increases with its augmentation and declines with its 
abatement. It is therefore a very valuable index to the com- 
parative condition of the part, and where we cannot see the 
color, nor note the swelling, nor perceive the heat, we have 
to rely a great deal upon the single local symptom observable 
by ns. The subject, therefore, is worthy of particular atten- 
tion. 

The cause of the pain in an inflamed part is not very ob- 
vious. The mechanical pressure of distended parts and 
strongly pulsating arteries upon irritated nerves, has more 
or less to do with the suffering. This is evident from the 
fact that increased pressure intolerably aggravates the pain. 
The slightest touch sometimes gives agony. In inflammation 
of the peritoneum, the patient will not bear the pressure of 
bed-clothes. Indeed, this sensitiveness of an inflamed part to 
pressure is so characteristic, that it enables us to distinguish 
spasm and neuralgia from inflammation. Yet it is plain that 
pressure is not the only cause of pain. The sensibility of 
the nerves is exquisitely exalted. As we have already said, 
a touch will sometimes cause a severe pang. The pain ap- 
pears before the distention, and where distention exists to 
the most fearful extent there is often no pain at all. Patients 
die of deep congestions without any acute sensations in 
the distended parts, and dropsies that press the viscera and 
distend muscles and skin to a frightful extent, create no 
such pain as would be felt in a moderate inflammation of the 
coats of one of the organs subjected to pressure. 

The pain of inflammation is, as we have said, continuous with 
it, and is indicative of its degree. It is also characteristic- as 
regards the tissue or organ in which it is seated ; a valuable 
fact in diagnosis. 

Sudden disappearance of acute inflammatory pain indicates 



68 INFLAMMATION AND ITS CONSEQUENCES. 

the occurrence of a change in the condition of the part ; but 
commonly a very unfavorable one. Inflammation does not 
suddenly get well — but free effusions may cause abatement 
of pain — so may the formation of pus — and the occurrence of 
mortification may relieve it altogether. Patients and their 
friends are often misled by the natural association of pain 
with disease, ease with cure. The degree of pain is affected 
by the natural sensibility of the organ in which it is seated. 
The skin being exquisitely sensitive, as the sentinel on the 
outpost of life must be, suffers much more when inflamed 
than muscle or cellular tissue. The parenchyma of or- 
gans is much less sensitive than the membrane that invests 
them. The hard unyielding character of the bones makes 
the process of inflammation in them very painful, until free 
discharge of inflammatory products is obtained. The inflamed 
mucous membrane gives out the burning sensation of the skin, 
but in a degree proportionate to the distance from the exter- 
nal tegument. The serous membranes are affected with a 
sharp, darting, lancitive pain. That of the cellular membrane 
differs very much according to its positions and relations. 
When in connexion with the skin, it partakes of the pun - 
gency which characterizes the inflammation of that sensi- 
tive organ; when the cellular structure of the internal vis- 
cera is inflamed, the pain is usually dull or obtuse, in conse- 
quence of the manner in which these viscera are supplied with 
nerves. 

When nerves are the seat of inflammation, very acute, 
darting pangs are felt, and the surrounding structures are ge- 
nerally very sore, tender, and more or less inflamed. In in- 
flammation of the muscles, the sensation is aching, mingled 
with a feeling of fatigue. The pain is greatly aggravated by 
motion. Inflammation of ligaments occasions sensations not 
very different. 

Pain is more or less severe in proportion to the degree of 



INFLAMMATION AND ITS CONSEQUENCES. 69 

the inflammation, the natural sensibility of organs, the yield- 
ing or unyielding character of parts affected, and the nature 
of the disease accompanying the inflammation. Certain spe- 
cific affections, such as cancer, occasion a peculiarly distress- 
ing, darting, and burning pain. Slight inflammation of the 
pulp of a tooth occasions intolerable agony. 

It is very important to study the natural expression of 
suffering peculiar to each organ, and indicative of the several 
forms of disease. Pain is not only characteristic, but it has 
its own symptoms in the correspondence of position, move- 
ment, and particularly of the countenance. These are often 
much more reliable than the words of the patient. 

The higher the grade and the more rapid the pace of in- 
flammation, the sharper will be the pain. The danger is not 
always proportionate, for the disease may benumb or depress 
the sensibility, and in such case the anxiety as to the result 
will be in inverse ratio to the pain. 

Spasm, or violent morbid contraction of a muscular part 
is attended with great pain. But it appears in full severity 
at first, relaxes and returns, and is not increased, often some- 
what relieved by pressure. For instance, a man in spasmo- 
dic colic presses upon his abdomen ; in inflammation of the 
bowels he lies upon his back and draws' up his knees to re- 
lieve pressure to the utmost. 

In neuralgia the nerve is the seat of violent irregular sen- 
sations of an exquisitely painful kind; but it remits, disap- 
pears and returns, — is attended with little vascular excite- 
ment, and is easily distinguished from the persistent ad- 
vancing pain of inflammation. 

Pain is not always reliable as indicating the true place of 
disorder. The ramifications of the nerves and the mysteri- 
ous laws of sensation that affect them not uncommonly cause 
the pain to be felt at a distance from the seat of injury. It 
frequently occurs that a painful tooth is sound, but is lend- 



70 INFLAMMATION AND ITS CONSEQUENCES. 

ing its nerve to a diseased neighbor. The whole arch of 
the jaw may be thrown into violent suffering by a single dis- 
ordered member. The shoulder may ache for the liver, and 
the knee for the hip, and the head for the stomach. Variety 
in the pain of inflammation indicates the change of stage in 
the process of the disease. In the early stage, before organic 
changes have taken place, the pain is burning or stinging. 
When suppuration is taking place, it becomes deeper and 
throbbing. This sensation seems to depend on the great 
obstruction existing, and the energy of the excited arteries in 
their attempts to overcome it. It is regarded as a symptom 
of a suppurative condition, or one that will terminate in sup- 
puration. The swelling of inflammation depends upon the 
distention of the vessels, and the accumulation of extravasated 
fluids. It is greatest when the tissues are least resistant, and 
by no means measures the amount of disease or danger. 
Where there is least swelling, as where the inflammation is 
confined by tight dense structures, the pain is excessive, and 
destruction of parts certain, unless artificial relief be given. 
Extravasation relieves the distended vessels, both mechani- 
cally and by taking off their highly stimulating contents. 

Redness. The redness of an inflamed part is caused by the 
greater amount of blood in the part. The vessels are dis- 
tended with redder fluid owing to the transudation of the se- 
rous elements. Capillaries ordinarily invisible are made red 
by an unwonted circulation, and extravasated blood adds its 
deep, sometimes livid, hue to the picture. 

The degree of redness varies with the ordinary vascula- 
rity and transparency of the part and the intensity of the in- 
flammation. Inflamed skin is less red than mucous membrane, 
and tendons less red than either. The tint indicates the cha- 
racter of the inflammation. When the disease is of a high 
character, the parts being in condition to make vigorous re- 
sistance to change, the color is bright — in reverse conditions 



INFLAMMATION AND ITS CONSEQUENCES. 71 

we find it darker, even to purple; "great attendant biliary 
derangement gives a yellowish, red." The color of inflamma- 
tion is fixed with great tenacity. It cannot be made to dis- 
appear before the inflammation subsides. Even fainting does 
not remove this color. It is, therefore, an important signal 
to the observer. 

Heat. A sensation of heat, sometimes very distressing, is 
one of the most common incidents to inflammation. It is 
partly a sensation and partly a fact. The thermometer shows 
an actual elevation of temperature, but the distress is out of 
proportion to the cause. The increase of caloric is no doubt 
due to the contact of an unusual amount of blood with the 
capillaries, one of whose functions is to separate caloric from 
the blood. The disordered and hyper- sensitive condition of 
the nerves accounts for the exaggerated sensations of the pa- 
tient. 

Disorder of functional sensibilities attends inflammation. 
The eye, even when slightly inflamed, cannot bear the light 
necessary to vision. The brain cannot endure the stimuli to 
its ordinary activity. The bladder will not retain its com- 
mon quantity of fluid. Inflamed, nature seeks rest and re- 
fuses activity. Hence functional activity is impaired or com- 
pletely suspended. 

The secretion of secreting organs is checked, suspended, 
and then altered. Sometimes it is thicker, more tenacious ; 
at others, thinner and acrid, reddening, or even excoriating 
the parts over which it flows. An abundant discharge of 
thickened secretion often precedes and seems to cause the re- 
lief of inflamed parts. 

Inflammation is capable of propagation. It always extends 
more or less from the point of commencement, but in bodies 
possessing ordinary power of resistance it is speedily limited, 
unless the cause of it continue to act. Inflammation spreads 
more readily in continuous tissues — as the skin, or mucous 



72 INFLAMMATION AND ITS CONSEQUENCES. 

or serous membrane — along which, under favorable circum- 
stances, it progresses very rapidly. When the powers of life 
are feeble, this spreading is more likely to take place. In some 
cases, there seems to be no power remaining to produce the 
changes necessary to prevent the continuous course of inflam- 
mation, and then a very trifling commencement may rapidly 
induce the most serious result. 

Inflammation sometimes spreads by the absorption of poi- 
sonous products from one part and conveying them to an- 
other. 

CONSEQUENCES OF INFLAMMATION. 

Inflammation never continues long without the superven- 
tion of certain results, often of greatly more importance than 
the primary phenomena we have described. 

Premising that when it passes away through mere subsi- 
dence of the heat, redness, swelling, and pain, without the 
formation of new products or destruction of tissue, the pro- 
cess is called Resolution, we may enumerate the consequences 
of inflammation as follows. 

Chemosis, (Edema, Suppuration, Vesication, Ulceration, Ef- 
fusion of fibrine, caries, and gangrene or mortification. 

Chemosis is the extravasation of blood. This is a mecha- 
nical result brought about both by the distention and pres- 
sure, and a change of quality in the blood itself. When 
thus effused it does not coagulate, and it remains in the tis- 
sues until it is absorbed, which often requires a slow process. 

(Edema is the extravasation of the serum, or watery parts 
of the blood. It is apt to attend debilitated condition, and 
seems to mark a lax condition of the coats of the vessels by 
which it is exuded. It is generally found in loose cellular 
structures, where the looseness of tissue affords little support 
to the walls of the vessels. It often attends a very low de- 
gree of inflammation, in debilitated subjects, and is unfavor- 



INFLAMMATION AND ITS CONSEQUENCES. 73 

able to recovery ; rather as a sign of debility than from any 
evil which it is likely to cause. (Edema may exist without 
inflammation, as when the veins fail to return their blood in 
due proportion to the rapidity of their supply, either because 
of mechanical pressure, disease of the heart, or any other cause. 
(Edema also attends certain specific conditions, as scarlet fe- 
ver, and may be produced by medicinal agents, as arsenic. 
When oedema is general, it is called "anasarca."* It is 
readily detected by the bloated translucent aspect of the 
skin, and by its loss of elasticity observed by its pitting un- 
der pressure. 

Vesication, or blistering, is the effusion of serum under 
the cuticle and rete mucosum, elevating them above the le- 
'vel of the surrounding surface, and separating them from 
the cutis vera. This may occur as the result of topical ap- 
plications of an irritating kind, or in consequence of local and 
constitutional disorders. This condition is frequently pro- 
duced as part of medicinal treatment, and gives the name of 
vesicatories to a class of means employed for this purpose. 

Suppuration, or the formation of a peculiar fluid substance 
called pus, is one of the most common and important of the 
consequences of inflammation. 

Pus, when pure, is thick, cream- like, yellowish, of a faint 
and peculiar odor, and somewhat sweetish of taste. It is not 
at all irritating. . To this kind of pus, the terms laudable and 
healthy have been applied. That which is thin, dark, and 
irritating, being considered unhealthy, because of the indica- 
tion it affords of the bad condition of sores, &c, which secrete 
it. 

. Although it is true that such pus as is called "healthy," 
indicates a convalescent state of an ulcer or abscess, yet the 
inference to be drawn from its appearance attaches exclusively 

* Ava o-a.Q% — throughout the flesh. 



74 INFLAMMATION AND ITS CONSEQUENCES. 

to the parts which, screte it : while it may herald the abate- 
ment of local inflammation, it may, nevertheless, give clear 
evidence of a state of disease incompatible with the integrity 
of organs, or with life itself. Suppuration of the eye, of the 
liver, or of the lungs, would be a very serious matter, how- 
ever " healthy " the pus might be. 

Some writers have considered suppuration a curative pro- 
cess, and have regarded the pus as a very valuable covering 
for the granulations. 

Although it is true that suppuration often intervenes be- 
tween inflammation and cure, and that the painful symptoms 
of inflammation abate or disappear after the copious secretion 
of pus, yet we must regard the formation of this matter, how- 
ever pure, as a great evil, though certainly preferable to 
others which occasionally affect inflamed parts, and it is one of 
the greatest cares of the surgeon and physician to prevent it. 

Pus may form in several situations. First. It may be 
found free upon the inflamed surfaces of parts, as the skin, the 
eye, and the mucous membranes, without any other apparent 
change of organization than an increase of the natural vascu- 
larity. Secondly. On the naturally unexposed surfaces of 
the body after they have acquired a new organization by in- 
crease of red vessels, and usually, if not always, by the addi- 
tion of coagulable lymph ; for it may be questioned whether 
in any instance the surfaces of the cellular, synovial, serous, 
and medullary membranes, the pia mater or periosteum can 
furnish genuine pus, without the deposition and organization 
of some coagulable lymph. 

The third situation in which pus is generated is the sur- 
face of the peculiar structures, called granulations, the vascu- 
larity of which exceeds that of all the natural surfaces of the 
body. The pus formed on the granular surface of an ulcer 
is the best example of this kind * 

* Macartney on Inflammation. 



INFLAMMATION AND ITS CONSEQUENCES. 75 

Some parts of the body have a much greater disposition to 
form pus when inflamed, than others. The cellular tissue, 
skin, and mucous membrane are very prone to suppurate, 
while the fibrous tissues manifest no disposition to it. 

Pus is modified by the nature of the part where it is formed, 
by the constitution of the individual, by various accidents, 
occurring in the process of its formation, and by certain ob- 
scure laws which control the phenomena of those affections 
which are called specific. It will also present different ap- 
pearances, as it may be mixed with other fluids, as blood, 
saliva, bronchial mucus, &c. 

If pus mixed with blood, serum, &c, be long confined un- 
der dressings, or in cavities, it becomes very offensive, and 
often irritating. If it be produced from the irritation of dis- 
eased bone, it is also very fetid. When thin, mixed with 
blood, and evidently "unhealthy," it is called "sanies." 

When pus is irritating, it is so, not to the surfaces which 
secrete it, but to the adjoining healthy structures over which 
it flows. 

Pus is heavier than water, and this quality frequently ena- 
bles us to distinguish it from mucus. It is coagulable by 
muriate of ammonia, which Mr. Hunter considered a pecu- 
liarity sufficiently marked to distinguish it from mucus, and 
all other natural secretions, but the accuracy of the test is 
disputed. 

Prom the fact that hard inflammatory tumors in the course 
of inflammation become soft and yielding, and filled with 
pus, it was naturally supposed that the original solid parts 9 
were converted into this fluid. It is now well ascertained 
that such is not the case, but that pus is furnished by the ar- 
teries. 

When pus is enclosed in a cavity formed in the progress 
of inflammation, the condition is called abscess* 

* Abscedo — I depart, denoting the loss of substance. 



76 INFLAMMATION AND ITS CONSEQUENCES. 

The phenomena of abscess are very curious, and through 
them nature succeeds in relieving the body of foreign mat- 
ters, and repairing extensive injuries. 

When a part capable of suppuration is subjected to in- 
flammation of the required intensity, some of the small vessels 
give way, and blood is effused into the surrounding parts. 
Simultaneously with this rupture, or nearly so, the arteries 
begin to throw out a peculiar plastic matter, which is called 
coagulable lymph. This is capable of becoming organized, 
and being thrown around the diseased parts, and between them 
and those which are healthy, it forms a barrier to the infil- 
tration of extravasated fluids. By some strange process, to us 
altogether inscrutable, the walls of lymph become vascular, 
and capable of performing the vital functions of secretion 
and absorption, and by them the pus is furnished. As this 
process proceeds, the previous contents of the abscess, in- 
cluding the effused blood, are gradually absorbed, and fresh 
pus deposited in their stead, so that if the tumor be opened at 
an early stage, the pus will be more or less mixed with blood, 
but if the opening be delayed, the cavity will be found to 
contain only pure pus. The process of suppuration is an- 
nounced by some relief of local symptoms, and a change in 
the character of the pain. It loses its burning sensation, and 
becomes throbbing, at the same time the tumor becomes softer, 
and at last fluctuates readily under pressure of the fingers. 
Yery often, and especially when the disease is extensive, or 
when it is seated in the viscera, the formation of abscess is 
announced by shivering or chill. 

While the arteries of the walls are depositing the pus, 
other processes equally obscure are moving the abscess to- 
wards the surface, and preparing for its evacuation. The 
bottom of the cavity is constantly contracting and filling up, 
while the opposite side is thinning and expanding. The ab- 
sorbents at one side of the abscess are busily engaged in re- 



INFLAMMATION AND ITS CONSEQUENCES. 77 

moving matter, while the arteries at the other are as actively 
supplying new material ; at the same time, a temporary organ 
made for the occasion, faithfully performs its peculiar func- 
tions, supplying pus, and removing mixed ■ fluids from the 
cavity. 

The parts lying upon the summit of the abscess are ra- 
pidly thinned, the tumor is pushed towards the surface, the 
skin ulcerates, an opening is made, and the pus evacuated. 
Though an abscess may discharge itself anywhere, there is 
evidently a strong disposition in such tumours to find their 
way to the outside of the body. In order to effect this, they 
will often traverse dense opposing structures when a nearer 
, opening through more yielding tissues might readily be ef- 
fected. Sometimes, when an abscess occurs in an important 
viscus, artificial adhesion will be formed between its surface 
and an adjoining structure, and a continuous canal being 
pierced through, then the pus will be ejected upon the sur- 
face of the body, or into another organ which has external 
communications. 

These most curious and interesting facts are so conclusive 
of wonderful design and contrivance, that it is impossible to 
regard them in any other light than as manifestations of di- 
vine and superintending Providence. 

Foreign bodies are removed precisely in the same way as 
pus. When the abscess has reached the surface, a thin point 
appears, which is soon perforated by a very small opening, 
through which the pus slowly oozes. The appearance of 
this thin projecting spot is called "pointing." 

Sometimes the parts which surround the abscess are too 
dense to permit the passage of the matter. When this is the 
case, great pain is often caused by the pressure, and the irri- 
tation produced by the vain efforts of nature to relieve the 
parts, may occasion very serious disease in adjoining struc- 



78 INFLAMMATION AND ITS CONSEQUENCES. 

tures. In some instances of this kind, as in abscess of the 
gums, or gum-boil, the pus failing to be evacuated, seems 
to be ultimately absorbed. 

When the attempt is made to form an abscess by weak or 
scrofulous constitutions, and in situations where the cellular 
substance is lax, the progress of the disease is very different. 
The first extravasation is serum, which passes easily into the 
loose cells of the cellular membrane with little or no injury 
to their structure. The parietes of the tumor are not com- 
posed in the beginning of organized and vascular lymph ; no 
genuine pus, therefore, is found in such cavities in the first 
instance: the fluid they contain is serous mixed with coagu- 
lable lymph, parts of which are found as flakes floating in 
the serum. As the cavities of chronic abscesses are not pro- 
voked, either by severe tension or the quality of the contained 
fluid, there is no preparation made for some time to remove 
their contents. These collections, therefore, often traverse a 
considerable distance along muscles or under plates of fascia, 
before they arrive at the skin, which ulcerates very slowly ; 
after which the cavities may inflame, their interior surface 
become more highly organized, and secrete genuine pus.* 

Ulceration is the process by which solutions of continuity 
are affected by vital processes and open secreting sores pro- 
duced. Inflammation is by no means necessary to this result, 
and some of the best writers upon pathology have declined 
to recognise it as one of the consequences of inflammatory 
action. Nevertheless, as ulceration does frequently occur in 
the progress of inflammation, and is an evil to be guarded 
against by the dental practitioner especially, it seems proper 
to consider it in this connexion. 

The process itself is very curious, and at first sight, the 
facts explanatory of it are hardly credible. It is not easy to 
comprehend how a body can destroy itself and take itself 

* Macartney on Inflammation. 



INFLAMMATION AND ITS CONSEQUENCES. 79 

away ; and the difficulty is not solved by the fact that only 
small portions are thus removed. Yet, there can be no doubt 
that such is the case, and we may silence, if not satisfy, the 
objector, by suggesting the equal difficulty of understanding 
how parts form themselves ; both facts, as Mr. Cooper ob- 
serves, are equally well confirmed. 

Every part of the body is continually undergoing waste 
and reparation. It seems that the molecules of tissues are 
constantly becoming effete, and having undergone some mys- 
terious change, are taken up by the absorbents and carried 
off to the several waste gates of the system, from which they 
are ultimately discharged. The bowels, the kidneys, the 
skin, the lungs, all the emunctories are continually at work, 
and all ultimately discharging the debris of the system. 

At the same time that this disintegration is going on 
through the action of the absorbents, another set of vessels, 
the nutritive arteries, are every where depositing new mat- 
ter. Bone receives bone, muscle is supplied with muscle, 
and viscus with its peculiar organic matter, so that the in- 
tegrity and form of each part, and of the whole, are exactly 
preserved. By some wonderful and inscrutable law, the ba- . 
lance of supply and demand is equally adjusted, yet not 
so positively as to lead us to infer that the action of the one 
set of vessels regulates that of the other. In childhood, the 
supply exceeds the waste, and the body grows : in maturity, 
the supply is regulated more by the wants of the man than 
the activity of the absorbents. If his vocation calls for in- 
creased strength of arm, the very use of the organ, instead of 
consuming, augments its volume. 

In truth, the two sets of vessels seem to be independent of 
one another, yet, like other parts, they naturally work to- 
gether for the production of the phenomena of life. 

It will readily be perceived that if any circumstance should 
increase the activity of the absorbents of a part beyond what 



80 INFLAMMATION AND ITS CONSEQUENCES. 

is usual ; and should not simultaneously stimulate the nutri- 
tive vessels ; or, should any circumstances render parts unu- 
sually susceptible of absorption, that the result would neces- 
sarily be an obvious loss of parts, and the interruption of 
their continuity. It is also obvious that the converse of these 
conditions would be attended with similar results ; for if nu- 
trition be impeded, either through defect of supply or any 
cause rendering the part less capable than usual of convert- 
ing blood into its own tissue, loss of volume, and breach of 
continuity might occur. For the most part, however, ul- 
ceration is nothing more than molecular devastation and 
waste, the products of which do not enter the absorbents at 
all, but are passed out with the more legitimate fluid pro- 
ducts of inflammation. 

Ulceration may result from any of these causes. Pressure 
is a common cause of ulceration, and acts probably by inter- 
rupting the circulation and nutrition of a part. Pressure 
may produce absorption and waste without causing ulceration, 
and the dentist, when fixing artificial pieces in the mouth, 
must be careful so to adjust his plates and springs as to avoid 
both of these evils. 

Inflammation probably produces ulceration in a manner 
somewhat similar ; viz. : by causing such impediment to cir- 
culation as prevents nutrition from being properly performed. 
It is also probable that the blood itself undergoes changes 
under the influence of inflammation, which render it less ca- 
pable of supplying the loss of parts. 

Diseased parts, and those which from any cause have become 
useless, and these only, are liable to be wasted by absorption. 
Unhealthy products, such as fungus,* are often removed with 
wonderful rapidity, and even bone will be removed when be- 
ing no longer needed, it has become foreign matter. The 
roots of the deciduous teeth are thus entirely removed, and 

* Fungus — a mushroom — proud flesh. 



INFLAMMATION AND ITS CONSEQUENCES. 81 

the dead fangs of permanent ones are subjected to continual 
waste from the same cause. That they are not entirely re- 
moved, is due to the comparative shortness of time which the 
present term of human life allows for the process, rather than 
to any resistance they are able to offer to the action of these 
all-subduing lymphatics. 

Extraneous substances are generally removed by ulcera- 
tion. Thus, a ligature will be separated from an artery, or 
a foreign substance from a wound ; no more of the surround- 
ing substance being absorbed than is necessary to loosen and 
dislodge the intruder. The process here is immediately de- 
structive, not vital. 

. By ulceration, also, dead parts are separated from the 
living, and the decomposed fragments removed to make room 
for new matter. 

Sometimes ulceration seems to produce great devastation, 
and is then called phagedenic* In such cases, it is evident 
that the ulceration is only the consequence of the destruction, 
not the cause ; for, until the parts have become too much en- 
feebled to subserve their natural purpose, they will not be 
subject to this rapid waste. 

All parts are not equally prone to ulceration. Skin, are- 
olar or cellular tissue, and mucous membrane ulcerate far 
more readily than blood vessels, nerves, or muscles. It is 
not uncommon to see these laid entirely bare of skin and cel- 
lular tissue, and bathed in pus, yet resisting disease. Ul- 
ceration would be much more 'destructive to parts and fatal to 
life but for this wise arrangement. 

The effusion of fibrine, more or less plastic, is a very im- 
portant result of inflammation. Exuded on the free surface 
of a membrane, it forms an adhesive layer upon it, called false 
membrane. The presence of this product is often fatal. Fi- 
brine may be exuded into the interior of parts, separating and 

* <baysiv — I eat. 



82 INFLAMMATION AND ITS CONSEQUENCES. 

compressing their molecules, impeding their function, and 
producing inflammation and suppuration in them. If the 
process be gradual, and the infiltrating fluid consist princi- 
pally of fibrine, it may harden, organize, and induce perma- 
nent induration of the invaded part. Under other circum- 
stances it may cause softening. Tumors may be formed by 
the deposition of successive layers of fibrine, or organs may 
be effectively destroyed by its presence, and the accidents 
that ensue. 

Organized fibrine is always of feebler texture than natural 
or original tissue, and the higher the grade of inflammation 
under which it has been effused, the less likely is it to be per- 
manent. Adhesions formed with the least attendant vascular 
excitement are the most secure. 

Adhesion is often consequent upon inflammation, though it 
does not require the previous inflammatory process. By the 
exudation of coagulable or organizable lymph, parts natu- 
rally separate or artificially divided, may be united. The 
process is of immense importance in arresting bleeding, 
closing wounds, and providing means of safe transit for pus, 
from deep-seated parts to the surface. 

Mr. Hunter calls ulceration the natural surgeon, and de- 
clares that even in the spreading of an ulcer there may be 
considerable advantage; and another writer very properly 
observes, that the same remark would apply to the effusion 
of lymph. The one acts like the surgeon that unites parts ; 
the other like the one who removes them, because they are 
not fit to remain; and it would not appear more justifiable 
to call adhesion and ulceration inflammatory processes, than 
to consider the operations of surgeons themselves as particu- 
lar modes of inflammation. 

The most disastrous result of inflammation is the absolute 
death of a part, reducing it to the condition of a foreign body, 
and subjecting it to the play of chemical affinities. 



INFLAMMATION AND ITS CONSEQUENCES. 83 

When this takes place in soft parts, it is called gangrene 
or mortification; in bones ; necrosis. The dead soft parts, 
when separated by ulceration from its connexion with living 
parts, is called sphacelus,* or slough, a fragment of dead bone 
is called sequestrum.f 

Caries is a condition of bone somewhat analogous to ulcer- 
ation of soft parts. Caries of the teeth is the result of chemi- 
cal agents acting from without, and decomposing their struc- 
ture: the j are, however, subject to necrosis as other bony tis- 
sues, and the fact of their being liable to a peculiar erosion, 
does not probably exempt them from the kind of caries ob- 
served in similar structures. If such idiopathic caries does 
occur in the teeth, it must be very rare, and is always con- 
founded with the erosive caries peculiar to these structures. 

CHAKACTEE OF INFLAMMATION. 

Inflammation may exist in any degree of severity, and 
move to its results with much difference of velocity. Yet it 
is common to speak of it as acute or chronic, though the 
dividing line cannot be exactly determined or accurately de- 
fined. 

By a chronic inflammation we mean one which progresses 
slowly, develops its results uncertainly, and does not tend 
to merge itself in those definite and well marked results 
which conclude active inflammation. It is sluggish in its 
movements, does not produce the acute distress of active in- 
flammation, occupies a long time without accomplishing a 
crisis, mostly stops short of suppuration and gangrene, fa- 
vors fibrinous exudation, and declines with hesitating, im- 
perfect convalescence. 

Chronic inflammation very often results in change of struc- 
ture, is at the bottom of a great deal of mysterious ill health, 

* ~Zqato} — I destroy. f Sequestro — I separate. 



84 INFLAMMATION AND ITS CONSEQUENCES. 

and withal is much less under the influence of medical treat- 
ment than acute inflammation is. 

Acute inflammation may become chronic by abatement 
and persistence. Chronic inflammation may become acute 
from various causes. Both changes are to be deprecated. 
When acute inflammation subsides into chronic, convales- 
cence will be tedious and very commonly imperfect. The 
part will rarely be restored to its original integrity. More 
or less of disease will linger in it, and inflammation will re- 
cur there' on slight provocation. Where chronic inflamma- 
tion becomes acute, the proper danger of the inflammation is 
aggravated by the feeble condition of the tissues to whose 
chronically inflamed condition it succeeds. 

The symptoms of chronic inflammation are all mild, in 
proportion to the length of time occupied in the prod action 
of the changes that constitute inflammation. When the 
disease is gradual, the vessels and nerves of the part become 
accustomed, or rather adjusted to the new condition, and 
extensive inflammation of a low grade may be firmly esta- 
blished before attention is called to it, or its pathology ascer- 
tained. The enlargement is slow, and the tumefaction formed 
is commonly firm, from the presence of fibrine, though serous 
or dropsical effusion often occurs. The constitutional symp- 
toms, which indicate the general sympathy of the system 
with some organ not performing its function properly, are 
very often our only guides to the true condition, and with 
these we are often very much perplexed about both the 
character and location of the disease. 

Inflammation is sometimes called Asthenic. Sthenic* in- 
flammation is that which occurs in parts or persons who have 
sufficient power of resistance to permit the inflammatory 
processes to be limited, through the remedial processes above 
described. Asthenic inflammation is that which is modified 

* 1&tvog, strength. 



INFLAMMATION AND ITS CONSEQUENCES. 85 

by the defect of healthful power in the subject. The pus is 
badly prepared — the exuded fibrine is not organizable — the 
products of the inflammation become irritants to parts 
unable to take on " healthy inflammation," — tissues readily 
break down, and the constitutional symptoms indicate that 
combination of weakness, and nervous and vascular distress, 
which is called Irritation. 

Phlegmon is the common form of inflammation in organs 
composed largely of cellular tissue. It is a form very com- 
mon in the mouth. Phlegmon may result from some local 
cause, as a blow or pinch, or contusion ; or contact with acrid 
matters. More commonly, in the mouth, it is the effect of 
inflammation excited by cold, or the irritation caused by 
diseased teeth. 

When phlegmon is seated in the subcutaneous cellular 
tissue, it presents a hard, circumscribed, red tumor, which is 
generally very painful. At first, the sensation is burning 
and darting ; subsequently, as the tumor softens, throbbing, 
or pulsating. After a longer or shorter time, according to 
the intensity of the inflammation and nature of the affected 
parts, fluid is felt to fluctuate in the tumor: in other words, 
an abscess, filled with pus, has been formed, the skin 
ulcerates, the matter is discharged, and the cavity is oblite- 
rated. 

What is called a boil, is the best example of genuine phleg- 
mon. It is a possible thing for a phlegmon to terminate 
naturally by resolution, but this very rarely happens, unless 
the incipient inflammation be actively combated by the 
resources of art. In by far the greatest number of cases, 
the best treatment fails to prevent suppuration, after the 
phlegmonous tumor has been fairly formed. 

Circumstances of position may vary the phenomena of 
phlegmon. If it be seated in important viscera, the consti- 
tutional symptoms will predominate very remarkably over 



86 INFLAMMATION AND ITS CONSEQUENCES. 

the local distress : if it be formed under aponeuroses or mus- 
cles, the tension occasioned by the resistance of these un- 
yielding tissues greatly aggravates the pain, while it pre- 
vents the swelling. The matter, not being able to escape, 
is extravasated among the adjacent tissues, and communi- 
cates irritation and inflammation as far as it reaches. Ulti- 
mately an opening may be made at a distance from the seat 
of the abscess : the pus may traverse a tortuous channel ; 
the cavity, not being properly emptied, may fail to heal, and 
a sinus, or sinous ulcer, may be the consequence. 

The pathological characteristic of phlegmon, is the effusion 
of coagulable lymph, by which the inflamed parts are walled 
in, and the pus confined within the cavity, and made subject 
to those obscure and curious processes by which it is ulti- 
mately evacuated. It is this limitation which gives to 
phlegmon its hard resisting character, and which, by im- 
peding the circulation, causes the deep red hue, which does 
not disappear upon pressure. To the same distention of 
vessels is due the peculiar pain of these inflammatory tu- 
mors. 

There is another form of inflammation which differs, in 
some important particulars, from phlegmon, and is called 
erysipelas.* 

This form of disease is peculiar to the skin and mucous 
membrane, and is far most usually met with in the former 
organ. It differs from phlegmon particularly in this, that it 
is not circumscribed by lymphy barriers, but is diffused 
until gradually lost in healthy parts. The effusion which 
occurs in erysipelas is serous. When the skin only is 
affected, the serum is effused under the cuticle, and occasions 
vesications. Sometimes the cellular tissue beneath the skin 
becomes inflamed together with it, and putting on its own 

• Eo£o» — I draw. rigAotf, near — from the tendency to involve surrounding 
parts. 



INFLAMMATION AND ITS CONSEQUENCES. 87 

phlegmonous condition, though imperfectly developed, forms 
a compound disease, which has been called phlegmonous 
erysipelas. The effused serum and unhealthy pus, diffused 
through the loose cells of the cellular tissue, carry destruc- 
tion to this substance, far and wide, among the muscles and 
beneath the skin, while the latter organ, ulcerating and 
sloughing, rapidly gives way before the advancing inflam- 
mation. 

This aggravated affection takes place in persons of debili- 
tated constitutions, and as the result of wounds and specific 
poisons. 

In erysipelas the circulation of the skin is not impeded, 
and therefore the pressure of the finger on the skin tempo- 
'rarily, removes the red color. The pain is burning, or 
stinging. 

Simple erysipelas does not tend to form pus, but ends by 
resolution or effusion. The constitutional symptoms attend- 
ing it, are generally much more serious than those resulting 
from phlegmon. 

Sometimes this form of disease occurs in the mouth, as the 
consequence of wounds, and even as an idiopathic affection. 
Sudden death is sometimes produced by the effusion of se- 
rum about the glottis — as the result of erysipelas affecting 
the larynx. This affection is called oedema of the glottis. 

Phlegmonous inflammation frequently occurs in the glands 
of the mouth, the tonsils, the gums, the pulps of the teeth, 
the lining membranes of the alveoli and antrum, and the 
tongue. Erysipelous inflammation in these parts is rare, but 
sometimes occurs in the mucous membrane, lining the gums, 
cheek, and palate. The submaxillary glands often take on 
inflammation from the effects of cold, and from the irritation 
produced by the presence of diseased roots in the alveoli of 
the lower jaw. The pain and difficulty of mastication, with 
the swelling of the gland, readily indicate the seat and cha- 



bb INFLAMMATION AND ITS CONSEQUENCES. 

racter of the disorder. Unless the inflammation be speedily 
subdued, and especially if it be the consequence of diseased 
teeth, the gland readily suppurates, discharging a very fetid 
pus, either into the cavity of the mouth, or externally, under 
the jaw. When the opening takes place internally, the flow of 
pus into the mouth is very disagreeable ; and the access to, 
and lodgment of alimentary matters in the suppurating 
gland often keep up the inflammation until an external issue 
is secured. 

Eemoval of the diseased teeth generally causes a speedy 
cure. Of other remedial means we will discourse hereafter. 

Inflammation in these, as in all glandular structures, is apt 
to leave permanent indurations. 

Inflammation of the tonsils is of very common occurrence. 
Its most common exciting cause is cold. The inflammation 
is generally very acute, rendering deglutition, and even 
speech, very difficult, and sometimes impossible. It is ge- 
nerally attended by severe constitutional symptoms. 

Tonsillitis or cynanche tonsillaris usually terminates by 
resolution, but very often by suppuration. Permanent en- 
largement and induration often ensue upon repeated attacks 
of the disease, and the swollen tonsils sometimes offer serious 
obstruction to respiration. "When this is the case, they may 
be removed with little difficulty, and without subsequent in- 
convenience. The palate and uvula are often the seats of 
inflammation. The latter is liable to erysipelas and oedema. 
The tonsils are also subject to a chronic inflammation and 
slow suppuration, which gradually wastes them away. 

The parotid gland is rarely the seat of inflammation, ex- 
cept when it is the seat of a peculiar specific disorder, which 
is called cynanche parotidea or mumps. Ordinary inflamma- 
tion, however, does occur in it. 

Inflammation of the lining membrane of the mouth is called 
stomatitis* 

* IrOfAa — the mouth. 



INFLAMMATION AND ITS CONSEQUENCES. 89 

Simple inflammation of this membrane is characterized 
by increased redness, swelling, and beat, but it rarely occurs 
except in connexion with inflammation of the tonsils, larynx, 
or pbarynx, or as the consequence of the irritation of denti- 
tion or of acrid or stimulating matters taken into the mouth 
for the purpose of allaying toothache. In such cases it ter- 
minates by resolution. 

It is much more common to find this inflammation pre- 
senting the appearance called "aphthae." 

These are grayish or whitish specks, which look like ul- 
cers, and are described as such by some authors, but which 
are exudations from the inflamed mucous membrane — when 
these fall off, the parts beneath are red and irritable, the cuti- 
cle being peeled off, and the cutis vera exposed. 

This disorder is generally supposed to indicate a corre- 
sponding disease of the surfaces of the digesting organs. It 
attends some forms of constitutional disorder, and constitutes 
a peculiar infantile disease called thrush, of which we will 
have occasion to say more in connexion with dentition. 

Stomatitis is not uncommonly a prominent attendant upon 
febrile and other constitutional diseases of children. Where 
the mucous follicles are the seat of the local inflammation, 
aphthous exudations, or minute follicular ulcers terminate the 
affection. When the substance of the gum is involved, pro- 
per ulcerative destruction of the gums is threatened, but in 
healthy children the disease usually progresses slowly, and 
disappears without permanent injury. When the ulceration 
appears in the cheek, rapid gangrenous ulceration often sets 
in and proves fatal. Writers upon infantile diseases express 
themselves too hopelessly with regard to this kind of ulcera- 
tion. Their experience is generally drawn from hospital ob- 
servation, and .hospitals are peculiarly deadly to children. 
In private practice I have found alarming ulceration of the 
7 



90 INFLAMMATION AND ITS CONSEQUENCES. 

cheek quite tractable to local stimulants and general con- 
stitutional remedies. It is, however, a very rare disease, ex- 
cept among children who are deprived of natural air and 
abundant wholesome food. In such, it is but the expression 
of a pravity of blood which cannot be restored to a healthful 
condition by drugs and washes. 

" Ulcerative Stomatitis," as the affection of the gum is par- 
ticularly called, frequently demands the attention of the den- 
tist. The gum is swollen, dark-colored, and ready to bleed 
when touched, and passes into ulceration without an attempt 
to form abscess. The ulcer is covered over with a yellowish 
or gray secretion, " which on removal by tepid water, leaves 
numerous red points scattered over a yellow ground. These 
points correspond to imperfect granulations, and the yellow 
ground to decomposing gums. The repeated application 
of a jet of water will carry away a farther quantity of 
the secretion, but it will fail to remove the shreds of dead 
tissue which lie between the less prominent parts of the 
ulcer. (Tomes,) 

The ulceration extends into the substance of the gums, 
laying bare the necks of the teeth and alveolar processes, 
and may reach the cheek. It occurs commonly in the ante- 
rior of the mouth, and on the labial surface of the gums. If 
the disease be not attended to, it may produce great devas- 
tation, laying bare alveoli, destroying teeth, and adding the 
parts thus destroyed to the primary cause of irritation. 

In children this disease is generally constitutional, and can 
only be remedied by constitutional treatment, in which fresh 
air and good food are by far the most important elements. 
Dr. "West thought he found very great benefit from the use 
of chlorate of potassa given in doses of three grains every 
four hours to the child of three years old. In two or three 
days, he says, manifest improvement followed, and cure was 
completed in a week or ten days. Nitrate of silver soon al- 



INFLAMMATION AND ITS CONSEQUENCES. 91 

ters the character of the ulcer. Lightly passed over it, the 
caustic produces a superficial slough which protects the sen- 
sitive surface, relieves the pain, and when the slough conies 
off, a healthy granulation is found to have been formed be- 
neath. A wash of five or six grains of chloride of soda, in 
an ounce of water, will abate the fcetor of the sore. 

Though we are inclined to believe that the efforts of na- 
ture, aided by the hygienic suggestions, purgatives, and tonics 
of Dr. "West, had more to do with the cure of his cases than 
the chlorate of potassa, the salt may, nevertheless, be useful, 
and at any rate can do no harm. 

A little irritable ulcer, which does not incline to spread, 
but which gives great annoyance, not unfrequently occurs 
on the mucous membrane of the mouth. It sometimes very 
seriously impedes the use of the tongue as well as the process 
of mastication. Touching the ulcer with nitrate of silver, or 
with a little nitric acid on a camel's hair pencil, will relieve 
the patient at once. 

Chronic Inflammation of the gum is quite common, espe- 
cially in persons of middle and advanced age in whom vital 
processes are less active than in youth. The extent and 
character of the inflammation are much modified by the local 
and constitutional circumstances attending it. Where it is 
excited by decayed teeth, it will be limited by their numbers : 
where it is but an expression of gastric disease, it will be 
more extensive and even less acute ; where it is a result of a 
general decadence, the asthenic character will be more ob- 
vious. In all cases it is, like chronic inflammation elsewhere, 
obstinate. 

The pain accompanying chronic inflammation of the gums 
is inconstant. It depends more upon the disordered sensi- 
bility of the part, and its liability to suffer under slight inju- 
ries and provocations, than upon its own morbid processes. 
From its position, the inflamed gum is liable to frequent irri- 



92 INFLAMMATION AND ITS CONSEQUENCES. 

tation, and may be kept in almost continual pain ; unless the 
patient learn to be watchful over it and protect it from cold, 
bruises and irritating applications; in other words, to pre- 
vent the chronic from being raised to acute inflammation. 
Yet more or less pain is natural to the chronic inflammation, 
especially when it involves the periosteum. Heavy, dull 
rheumatic aching is then frequent and prolonged. 

The result of the disease, if suffered to progress, is to waste 
the alveoli by absorption, or to provoke the nutrient vessels 
to meet the threatened waste by a deposit of unhealthy po- 
rous bone, which itself becomes an irritant and aggravates 
the malady. 

In the first case, the teeth are loosened and lost by the re- 
moval of their sockets ; in the latter, by the extension of the 
disease to the alveolar periosteum. (Tomes.) 

The treatment of chronic inflammation of the gums is very 
simple, so far as it can be comprised in local attention. 

If engorged and turgid, free scarification may be premised. 
In this case the lancet is better than leeches, as the latter in- 
flict a wound which, on unhealthy and feeble parts, readily 
becomes a troublesome sore. After scarification, or without 
it, if the parts manifest no great turgescence, astringent ap- 
plications are most useful. Tannin, in a powdered state, 
may be rubbed over the gums. The edges may be touched 
with nitrate of silver. Washes containing alum, myrrh, Pe- 
ruvian bark, oak bark, &c, may be used. The most impor- 
tant thing to be done, however, is to remove all the loose 
and decayed teeth which may seem to cause or perpetuate 
the trouble. If the patient chews tobacco, he must abandon 
the filthy and noxious habit, at least, until the result of 
abstinence be seen. 

Constitutional disease, manifesting itself in the mouth, must 
seek constitutional treatment from the physician. 

u There is a singular condition of chronic inflammation of 



INFLAMMATION AND ITS CONSEQUENCES. 93 

the gums, in which, instead of becoming thickened and irre- 
gular on the surface, they seem rather to decrease in size, 
assume a very smooth and polished surface and mottled as- 
pect ; at the same time, the disease may extend over the sur- 
face of the hard palate. The malady is attended with acute 
intermittent pain, which may be confined to one side of the 
mouth, or even to half of the upper jaw. It very commonly 
comes on in the evening, and keeps the patient awake half 
the night. The patients suffering from this complaint, who 
have come under my notice, have been, for the most part, 
poor middle-aged females in whom menstruation was be- 
coming irregular or had altogether ceased, and they have al- 
ways been cured by the use of a mild aperient, such as sul- 
phate and carbonate of magnesia, given in small doses twice 
a day. Under this treatment the pain in the gums will pro- 
bably cease within a week or nine days, and their restoration 
to a healthy condition will speedily follow." (Tomes.) 

I have never seen the disease above described, but from 
the brief description it does not seem to be chronic inflam- 
mation, but rather a tendency to atrophy, attended with neu- 
ralgic pain. It is very doubtful whether the treatment 
"cured" the patients, though moderate purging might bene- 
fit them. I will not advise, however, even a small dose of 
Epsom salts, " twice a day," for " nine days." Active and 
even dangerous hyper-catharsis might result from such long 
continued, though moderate irritation of the intestinal canal. 
After a moderate purge, I would rely upon opium and tonics 
for the relief of such a case. The disease, however, is very 
obscure. 

The most common cause of inflammation in these parts, is 
the irritation produced by dead teeth. We have already ob- 
served that dead parts are subject to the same laws which af- 
fect foreign bodies lodged in the flesh, and nature removes 
them, or attempts their removal by instituting inflammation 



94 INFLAMMATION AND ITS CONSEQUENCES. 

and ulceration around them. In other words, it is provided 
in the fundamental laws of the animal economy, that dead 
parts shall irritate the surrounding parts, and produce in them 
those conditions which naturally lead to the expulsion of the 
offenders. But dead teeth are firmly set in the jaw, and with- 
al are of too dense structure to be readily softened and ab- 
sorbed. It happens, therefore, that they remain long after 
their partial or complete disorganization, to plague the soft 
parts with which they are connected. The gums under these 
circumstances are kept in a state of chronic inflammation, 
and are rendered exceedingly sensitive to the action of irri- 
tants. Cold, or any local application of an exciting kind, 
will, under these circumstances, occasion aggravation of the 
chronic affection, and cause acute inflammation of a severe 
character, which is remarkably liable to end in abscess. 

The chronic inflammation is often attended with ulceration 
around the decayed tooth; the soft parts being separated 
therefrom, in the vain attempt of nature to remove them. In 
consequence of the long-continued and unavailing ulceration, 
an imperfect attempt is made by the vessels of the gums to 
supply the loss of parts by granulations. These are un- 
healthy, spongy, loose, and incapable of cicatrizing ; in other 
words, they are fungus. These fungous growths bleed free- 
ly upon being touched with a brush or hard body, and 
being constantly destroyed and renewed, add much to the 
foetor of the fluids of the mouth, which under these circum- 
stances, is often intolerable. Inflammation of the pulp, and 
the lining membrane of its cavity, is commonly, perhaps al- 
ways, the consequence of caries of the bony structure of the 
tooth, and exposure of its sensitive internal parts to the ac- 
tion of external agents. It gives rise to violent pain, which 
only subsides to be renewed again by contact with any hard 
body, or irritating substance. This inflammation may con- 
tinue for a considerable length of time, passing through sue- 






INFLAMMATION AND ITS CONSEQUENCES. 95 

cessive suppurations, and ultimately completely destroying 
the vessels and nerves of the pulp, and with them, the vi- 
tality of the tooth. 

Sometimes the matter formed within the tooth perforates 
the alveolus and the gum, and forms a fistulous* orifice into 
the mouth, through which putrid fluids are continually weep- 
ing. This is what is called alveolar abscess, and can only 
be remedied by extraction of the tooth. 

The matter of alveolar abscess will sometimes be discovered 
at a great distance from its source. The following case, 
which occurred in my practice, and which is related in Prof. 
Harris' Dental Surgery, as the most singular case of alveolar 
abscess which ever fell under his observation, affords a 
striking instance of this fact. 

The subject was a lady about thirty years old. She consult- 
ed me on account of a continual dripping of pus from behind 
the curtain of the palate, which she attributed to some dis- 
ease of those parts, and which had annoyed her for a year 
previous. 

Upon a close examination of her mouth and throat, I could 
discover no tumor or any indication of a deposit of matter, 
except two protuberances, each nearly as large as a hazelnut, 
situated behind the two superior central incisores. Being 
strongly inclined to believe that the matter came from these 
abscesses, I requested the advice of Prof. Harris, who fully 
coincided in my suspicions. Upon our joint advice, the pa- 
tient submitted to lose these valuable teeth, and was reward- 
ed by cure of the troublesome complaint which had caused 
her so much uneasiness. 

The maxillary sinus, or antrum, is covered by a mem- 
brane which nearly resembles the mucous covering of the 



* Fistula — a pipe, a canal whose sides and edges are hard and 'incapable 
of adhesion. 



96 INFLAMMATION AND ITS CONSEQUENCES. 

mouth. This is frequently the seat of inflammation. From 
the protected situation of this cavity, locked in on every side 
by bone, and covered by thick integuments, it is not apt to 
be affected by ordinary agents acting from without, but the 
teeth of the upper jaw frequently send their roots into it, 
and thus affect it readily, when, happening to become dis- 
eased, they are qualified to provoke disorder in neighboring 
parts. Even when they do not penetrate the floor of the an- 
trum, they are often separated from it by a partition so very 
thin as to afford no adequate protection to the antral mem- 
brane against the propagation of inflammation. 

When the membrane of the antrum is inflamed, it pours 
out a vitiated secretion, which accumulates for some time 
before it produces sufficient uneasiness to excite the attention 
of the patient. The pain of inflammation depends largely 
upon the degree of pressure to which the parts are subjected, 
and the peculiar structure of the antrum prevents much 
suffering from this cause until the cavity is completely filled. 

Generally, however, some dull pain is felt in this region 
in the course of the inflammatory action, but the patient 
commonly refers it to the teeth. After a while, however, 
the distention of the walls of the cavity produce more serious 
suffering, matter escapes through the nose or mouth, and a 
hard bony tumor indicates the projection of the antral 
walls. 

The fluid thus accumulated is usually not pus, but vitiated 
mucus. The disease has been very improperly called dropsy* 
of the antrum, for the contents are by no means serous. 

The discharged matter having been long retained, is ge- 
nerally very offensive. 

Ulceration may also take place in the membrane of the 
antrum, and pus of a very fetid quality be exuded through 

* n.SwQ — water. 



INFLAMMATION AND ITS CONSEQUENCES. 97 

the nose, and when an opening exists, through the month. 
This condition forms one of those exceedingly distressing, 
and often incurable cases of disgustingly fetid breath, which 
are called ozena. 

Sometimes, when the disease is permitted to proceed with- 
out proper remedial means being used, the walls continue to 
swell, the bones soften, the tumor opens, and a fetid discharge 
flows through the aperture over the cheek. 

Inflammatory Fever. 

Fever,* or pyrexia, f is a morbidly increased activity of 
the heart and arteries, the proximate cause of which is little 
understood, but which is attended with general disturbance 
of function. 

Merely increased action of the heart and arteries is not 
fever, for such excitement may be purely physiological and 
attended with no functional distress. Violent exercise and 
mental emotions will frequently cause the vascular system 
to work with vastly greater energy than usual, while the in- 
dividual who is the subject of the accelerated circulation will 
not be at all morbidly affected. 

But in fever, the increased vascular action is the effect of 
disturbing morbid causes. Often, perhaps always, the blood 
itself has undergone change, and the vital fluid thus altered 
being supplied to all the organs, begets universal disorder 
of function. 

Fever is either idiopathic, :f or symptomatic. 

By idiopathic fever we mean that form of it which appears 
to us to represent the primary or original disorder, § being 
the first observable effect of the morbific cause. Such fevers 
are not, so far as we know, preceded by a local disease, whose 
existence or intensity is represented by the vascular ac- 

* Ferbeo — I burn. f Tlup — fire. % J^«w» proper, or peculiar. 
ZTlado;, disease. 



98 INFLAMMATION AND ITS CONSEQUENCES. 

tion. We cannot, in the present state of our knowledge, go 
behind the fever to find out its immediate cause, in struc- 
tural change, or functional error. 

Symptomatic, or secondary fevers, or, as they are often 
called from the nature of the conditions they most frequent- 
ly represent, inflammatory fevers, are merely consequent 
upon local disease, having no independent existence, but 
rising and falling with the flow and ebb of the disorder 
they represent. 

These two conditions, though called by the common name 
fever, are entirely distinct and different in their cause, na- 
ture, progress, and treatment, and are only allied together by 
the fact, that each of them is attended with morbidly in- 
creased vascular action. 

Neither is symptomatic fever a unit ; for when it repre- 
sents inflammation, it differs essentially from the vascular 
condition, which is consequent upon another state which is 
called irritation, and which seems to consist in a merely aug- 
mented sensibility of a part, and the distress occasioned 
through it. 

The sensible peculiarity of inflammatory fever consists in 
two elements ; the hardness of the pulse, and the huffy coat 
of the blood. 

In all kinds of fever, the pulse may be quick and frequent, 
but as a general rule, to which the exceptions are very few, 
we may regard hardness as indicative of inflammation. 

When blood is drawn in a full stream from the veins of a 
patient laboring under inflammatory fever, it will, upon co- 
agulation, present a fibrinous surface of a yellowish hue, the 
abundance of which will, to a great extent, mark the inten- 
sity of the inflammation it represents. Yery often, too, it 
will assume a peculiar form, being depressed in the centre 
and raised at the edges; an appearance which is called 
" cupped," though the resemblance is nearer to a saucer. 



INFLAMMATION AND ITS CONSEQUENCES. 99 

It generally happens that this appearance is more mani- 
fest after the disease has progressed several days than in its 
incipiency ; and is often more observable upon a second, than 
a first bleeding, a fact which has led to the very erroneous 
opinion, that the abstraction of blood favored this kind of 
alteration. The best mode of observing this buffy coat is 
to catch the current of blood in a deep narrow vessel, such 
as a wine or jelly glass. 

Inflammation of fibrous tissues produces more of the buffy 
coat than is found consequent upon the same disease in other 
structures. 

It must be remarked, however, that the buffy coat is found 
upon healthy blood drawn from pregnant women. It is occa- 
sionally, but rarely met with when the circulation is mor- 
bidly active from other causes than innamation. Mercurial- 
ization also imparts this appearance to the blood* 

Treatment of Inflammation. 

In all cases of inflammation it is desirable to bring about 
the disappearance of the disease without any disorganiza- 
tion of structure. In other words, to accomplish cure by 
resolution. When this cannot be effected, it is important to 
lessen suppuration, and if possible to prevent, or, at least, 
limit mortification. 

The first step towards accomplishing the cure of inflam- 
mation is, to remove, if we can, the cause which produces it. 
This will often render further treatment very simple and 
easy, or altogether unnecessary. Where the gums or lining 
membrane of the antrum are inflamed through the irri- 
tation caused by diseased or dead teeth, no treatment short 

* The author had one patient laboring under slight enlargement of the 
heart, whose blood always presented a buffy coat. In a somewhat extensive 
practice of nearly twenty years he has never found the blood of an inflamma- 
tory patient without it. 



100 INFLAMMATION AND ITS CONSEQUENCES. 

of their removal will do any good ; and this will generally be 
a sufficient aid to nature. Even when the soft parts are 
suppurating, they will speedily heal after the irritant has 
been removed. 

The treatment of inflammation proper consists in general 
and local means. With the exception of a few employed to 
relieve chronic inflamed conditions, these remedial measures 
are comprised under the general name antiphlogistic* and are 
all intended to lessen the vascular action of the general or 
local circulation. 

Antiphlogistic treatment is negative or positive. The 
negative consists in withholding every local application like- 
ly to excite the vessels, or irritate the morbidly sensitive 
nerves of the part ; and preventing the taking of such drinks 
or aliment as would tend to sustain the morbidly active cir- 
culation. In short, the withdrawing as far as possible of all 
local and general excitants. 

The positive treatment consists in the use of means which 
lessen vascular action and diminish nervous sensibility. The 
general remedies are blood-letting, purgatives, diaphoretics, 
and low diet : among the local are blood-letting from the af- 
fected part or its immediate vicinity, cooling, emollient, se- 
dative and astringent applications, and counter-irritants. 

When pus has been formed in a cavity, it is often ne- 
cessary to evacuate it by an artificial opening: sometimes, 
even after the tumor has opened spontaneously, a counter 
opening is necessary. 

Treatment of Inflammation and Abscess of the parts composing 

the Mouth. 

It is rare that inflammations of these structures require 
general treatment. Sometimes, however, they are suffi- 
ciently serious to occasion inflammatory fever, and call for 

* Anti, against — Phlogiston, the old name for the cause of heat. 



INFLAMMATION AND ITS CONSEQUENCES. 101 

decided constitutional remedies. When such is the case, 
the patient should be bled from the arm until a decided im- 
pression shall have been made upon the circulation, and 
the operation must be repeated, till the desired effect be ac- 
complished. If the bowels of the patient be constipated, sa- 
line cathartics should be. employed. Nauseating remedies, 
such as tartar emetic, will also be found useful in lessening 
the general inflammatory action and withdrawing the ner- 
vous sensibility from the affected part. 

In most cases, however, the dental surgeon will only need 
to employ local remedies. 

"We have already said that when the inflammation is con- 
sequent upon the presence of diseased teeth, or parts of 
teeth, they must be removed. This being done, the inflam- 
matory action will commonly subside and speedily dis- 
appear. The teeth are liable to a peculiar calcareous de- 
posit, called tartar,* or salivary calculus, which adheres 
with great tenacity to them, and insinuating itself under the 
edges of the gums, detaches them from the teeth, and acting 
as a perpetual irritant, inflames, and often ulcerates them. 

This substance is deposited from the saliva under certain 
conditions of that fluid, and is most liberally deposited upon 
the teeth nearest to the salivary ducts and upon those of the 
lower jaw. When it contains a larger proportion of earthy 
salts, it is hard and brittle ; when the animal matter is in ex- 
cess, it is soft and moist. Under whichever of these forms 
it appears, its removal is indispensable to the successful treat- 
ment of the disease of the gums which it causes. Sometimes 
this can be effected by the brush alone : often the hard mi- 

* Tartar, or salivary calculus, is composed, according to Berzelius, of 
Phos. lime and magnes. 79.00 

Salivary mucus and salavine, 13.50 

Animal matter, 7.50 

100.00 



102 INFLAMMATION AND ITS CONSEQUENCES. 

neral substance requires to be broken up and elevated by an 
instrument of steel. When once removed, its subsequent ac- 
cumulation must be prevented by persevering use of water 
and the brush. 

It often happens that the gums will be inflamed through 
the agency of teeth, the disease of which is not sufficiently 
serious to authorize their removal : again, inflammation may 
occur in the gums from causes independent of the teeth, as 
from cold, irritating applications, bruises, &c. 

In order to prevent acute inflammation of the gums from 
passing rapidly to suppuration, it is necessary to use free lo- 
cal depletion. This may be done by scarification or by 
leeching. 

Scarification is nothing more than slightly incising the 
gum and causing its superficial vessels to bleed. 

It is a remedy of doubtful utility, and often does more harm 
than good. 

It is obvious that any wound inflicted upon an inflamed 
part must increase the inflammation to a certain extent, and 
unless the quantity of blood taken away be more than suffi- 
cient to counterbalance the additional evil inflicted, the pa- 
tient will lose by the operation. Scarification produces co- 
pious bleeding for the instant, but the clean superficial wound 
is soon closed by coagulum, and lymph, and the oozing of 
blood continues but a short time. 

When the gums present the condition called fungus, scari- 
fication will cause much freer bleeding, owing to the increased 
vascularity of the part. Under such circumstances it is an 
important means of cure. 

Leeching is a far more effectual process. It is true that 
wounds are made by the leeches deeper and more irritating 
than those inflicted by the lancet, but the flow of blood con- 
tinues very much longer and the quantity discharged is far 
greater. 



INFLAMMATION AND ITS CONSEQUENCES. 103 

Two or three leeches placed upon a gum will often cause 
a bleeding which, will continue for several hours, and will 
cure severe inflammation in almost as brief a space of time. 

In order to be effectual, leeching should be employed in 
the early stage of inflammation. If delayed until matter has 
begun to form, no benefit can be expected, except, perhaps, 
in the lessening of the quantity of pus. 

Other local applications are of little or no use in the treat- 
ment of acute inflammation of the gums. Their position 
prevents the continuance of any fluid substance upon them. 

It is better to apply the leeches on the part adjacent to the 
inflamed spot, unless we can apply them with the expecta- 
tion of utterly breaking up the disease. In the latter case 
we may apply them directly. If the inflammation be active, 
after the leeches fall off, the flow of blood, being directed to 
the orifices from the adjacent parts, and immediately filling 
the enlarged vessels, will tend to render the bleeding nugatory. 

To apply leeches it is best to confine them in a glass or 
wire tube with the small opening applied to the part, per- 
mitting the head to protrude. Their bite can be thus directed 
to the proper place. The part must be freed from hair and 
neatly cleansed. A small spot of blood upon it is sometimes 
necessary to incite the leech to bite. On the mucous mem- 
brane this is not necessary. If the leech be sluggish, it may 
be excited by dry friction ; or in cold weather, by dipping 
it in warm water and rubbing dry with a towel. The blood 
that a good leech will take or cause to flow, may be esti- 
mated at an ounce to an ounce and a half. Three or four 
will often produce a very decided constitutional impression 
upon a child a year old; and it is never safe to leave a child 
at night, after having leeched it, until the bleeding shall have 
ceased. Protracted and exhausting hemorrhages may result 
from even a few bites. It is well, therefore, in applying 
leeches, to place them on a part which will admit of firm 



104 INFLAMMATION AND ITS CONSEQUENCES. 

pressure. They should not be put on parts that are liable 
to frequent movement, nor over superficial veins ; nor on the 
neck, face or arms of females, as they are apt to leave per- 
manent scars. 

To stop the bleeding of leech bites a number of expedients 
may be resorted to. Firm pressure with a little lint charged 
with some astringent, as Kino, or catechu, or alum, will com- 
monly arrest the bleeding very soon. Should this fail, as it 
may, particularly when the bleeding is from the gums where 
pressure cannot be so readily applied, a pointed pencil of ni- 
trate of silver pressed into the orifice, and held there for a 
few seconds will rarely fail. Should it do so, a ligature may 
be passed through the lips of the orifice and closure mechani- 
cally effected. 

All stimulating applications used to irritate the surround- 
ing parts, and thus alter and divide sensation so as relieve 
pain, ultimately aggravate the disease. It is erroneously 
supposed that the increased flow of secretions which is occa- 
sioned by the irritation, must relieve the vessels and abate 
the inflammation, for the very irritation attracts to these 
parts a larger supply of blood than usual, and augments se- 
cretion only by increasing arterial activity.* 

Where the inflammation is excessive, leeching and blister- 
ing behind the ears or under the jaws may be resorted to. 

As great and long-continued suffering frequently attends 
this disease, full opiates at night may be given with great 
advantage, securing at once temporary relief and grateful 
repose, and aiding materially the efforts of nature to remove 
the inflammation. 

At first sight, cold would seem to be the readiest and most 



* Ubi irritatio, ibi fluxus — where there is irritation, to that place will be 
the flow, is a well known medical adage. The law applies to the nervous as 
well as the vascular system. 



INFLAMMATION AND ITS CONSEQUENCES. 105 

effective means of combating inflammation, and it would be 
so if we could control its application so as to bring the deep- 
er seated parts of the inflamed spot under the same degree 
of temperature as the superficial. Even then ; cold would 
not be useful after effusion had taken place and the suppura- 
tive processes begun. Cold tends to prevent inflammation 
and limit its extent and abate its intensity, but its proper 
time is in the very early, determining stage of the affection. 
It cannot be used with any steadiness or prospect of advan- 
tage in inflammation of the gums. 

Warmth and moisture are the requirements of advancing 
inflammation. These are applied by means of poultices and 
fomentations. To the inside of the mouth, vapor of hot 
water is the best vehicle. 

Counter-irritation is the artificial production of excitement 
in a sound, in order to divert the flow of blood from a 
diseased part, and also to withdraw from it the nervous 
concentration which seems to be mysteriously connected 
with the attention of the patient's mind. The remedy is a 
very efficient one when applied at the proper time, but 
it may be decidedly injurious if attempted too soon. In the 
acuter stages of the inflammatory process, when the action' 
is at the highest, artificial excitation only increases the mis- 
chief. When the acute inflammation has been abated by 
blood-letting or by time, counter-irritation often gives great 
relief. It must be observed, however, that in the very early 
or forming stage of what would probably prove slight in- 
flammations, simple counter-irritation often relieves the af- 
fected part. Every body has tested the efficiency of a woolen 
stocking, or mustard or pepper plaster to the throat for the 
relief of commencing soreness there. 

Rubefacients are counter-irritants of the mildest character. 
They redden the skin, but do not cause blistering nor sup- 



106 INFLAMMATION AND ITS CONSEQUENCES. 

puration. They produce only hyperemia or fulness of 
blood, not inflammation. A number of substances are used 
for this purpose — mustard is the best. It must be kept on 
only until it has reddened the part, or it may cause an ugly 
blister. It may be mixed with flour, and made as much or 
little irritating as we please. A mustard plaster is known 
in medicine as a sinapism. 

Vesicants are counter-irritants of greater activity, or used 
to produce more profound and continued action. They not 
only bring blood to the surface as the rubefacients do, but 
they evacuate it, and thus really lessen the quantity in cir- 
culation. 

The principal agent for this purpose is cantharides or 
Spanish flies — insects whose dried bodies contain a peculiar 
acrid principle, called cantharidin. Eeduced to an ointment, 
or dissolved in liquid, cantharides are used to produce blis- 
tering or vesication. The application acts slowly, usually 
requiring several hours to produce its effect, which, however, 
is more durable than when it is more rapidly induced. 

Aqua Ammonias, or hartshorn, is sometimes used to pro- 
duce vesication. It does so very rapidly, and with great 
pungency of sensation. Sometimes essential oils are added 
to the ammonia to make it more irritating, and the lotion is 
applied to create a sudden and violent diversion of sensation, 
as in neuralgic cases where the pain is very severe. 

Suppurants are means used to produce inflammation and 
suppuration, in order to procure a continued and deep -reach- 
ing counter-irritation, combined with evacuation. 

Tartar Emetic — Tartras Antimonii et Potassa3 — is used to 
produce a crop of pustules upon the skin. 

Groton Oil is used for a similar purpose. 

A Seton affords a more sure and enduring purulent drain. 
It is a wound converted into a running sore by the presence 



INFLAMMATION AND ITS CONSEQUENCES. 107 

in it of a foreign body, preventing closure and keeping np 
irritation. 

The manner of making it, is to take np the skin with the 
fingers and pierce it with a broad needle, carrying a skein of 
silk or India-rubber tape, which is left in the wound. Warm 
poultices are then applied until suppuration is established. 
The thread must be moved once or twice a day, both to favor 
cleanliness and keep up irritation. 

The India-rubber tape is much the best. As it does not 
absorb the pus, it is cleaner and much more durable. 

An Issue is also a discharging sore, but it is an open one, 
produced by laying open the integuments with a knife or 
with caustic, and inserting peas, or some other foreign sub- 
stance to prevent closure. The knife is better than the caus- 
tic, but patients prefer the latter, and it is commonly used. 
Caustic potash is the best article for the purpose. It is ap- 
plied until it produces a slough, and the raw surface thus 
obtained is prevented from granulating by the presence and 
pressure of foreign bodies. 

The Actual Cautery, that is, burning by the application 
of a hot iron or a combustible substance in ignition, is a 
powerful means of counter-irritation, the use of which can 
only be justified by extreme necessity, and where the pros- 
pect of advantage from its use is more than conjectural. 
There are cases where this frightful means may be resorted 
to with propriety, as when there is " advancing destruction 
of texture in the bones of joints," and certain "chronic affec- 
tions of internal organs, as the kidneys." The Moxa was 
very fashionable a few years ago. It is a conical or cylin- 
drical roll of rapidly and steadily combustible substance — 
commonly cotton — dried after immersion in a solution of 
Nit. Potass. (Saltpetre.) This is either held over or on the 
part, as it is desired to produce more or less impression 
from that represented by mere redness, to absolute destruc- 



108 INFLAMMATION" AND ITS CONSEQUENCES. 

tion of the integuments. The Moxa was for a time much 
used in chronic diseases of deep-seated parts, in neuralgic af- 
fections, and very often where it would have been difficult 
to give any philosophical reason for its application. 

In the latter stages of inflammation, stimulants are often 
required, especially if the disease has been protracted. The 
parts are left in a condition from which they cannot restore 
themselves without aid. The capillaries, long distended, are 
slow to contract to their proper diameter — the absorbents 
need aid to enable them to remove effused fluids or denser 
products of disease. Mechanical pressure is often needed to 
support the enfeebled tissues. Friction may quicken the 
sluggish vessels, and excite the dull nervous sensibility. 
Properly tempered stimulants may cause the capillaries to 
contract and the absorbents to resume their functions. Some- 
times we can only use these means through the circuitous, 
but often most powerful process of constitutional medication. 
Mercury has often a wonderful influence over the conditions 
induced by inflammation, and Iodine is very potent in sti- 
mulating the absorbents to action. 

Inflammation from mechanical violence must be treated 
upon the same principles. 

The gums are liable to inflammation of a specific character. 
When mercurial preparations have been used to a certain ex- 
tent differing much in different individuals, a constitutional 
impression is obtained, which announces itself by a peculiar 
tenderness and inflammation of the gums and an increased 
secretion of mucus and glandular fluids into the mouth. This 
is called salivation or ptyaiism.* 

The first symptoms of this mercurialization are observed 
in an increased tenderness and some swelling of the gums 
which exhibit a pale rose color, except at the edges sur- 

* Ptyalism — salivation, from mua> — I spit. 



INFLAMMATION AND ITS CONSEQUENCES. 109 

rounding the teeth, where they are of a deep red. The sore- 
ness and swelling now rapidly increase, the discharge of 
mucus and saliva becomes excessive, and is accompanied by 
a very peculiar and disagreeable odour ; a metallic or coppery 
taste is constantly present in the mouth, and the tongue and 
salivary glands are inflamed and swollen. 

Such is moderate salivation, but it sometimes happens that 
from excessive dosing with mercury or from peculiar suscepti- 
bility of the patient, all the symptoms above enumerated are 
greatly aggravated. The gums are very much swollen and 
covered with ulcers; the enormous tumor of the tongue 
pushes beyond the lips and hangs out of the mouth, prevent- 
ing the closure of the jaws; the flow of fluids is prodigious, 
the patient wastes excessively, gangrene of the mucous mem- 
brane of the mouth and gums, and. extensive sloughing, of 
the soft parts and bones sometimes occurs; the teeth are 
loosened and sometimes drop from their sockets, and occasion- 
ally the patient expires from exhaustion. 

A very frequent consequence of extensive mercurial sali- 
vation and the attendant ulceration and sloughing, is con- 
traction of the mucous membrane in the neighborhood of the 
anterior arches of the palate, whereby the patient is prevent- 
ed from opening the mouth except to a very slight extent. 
In one case this condition resulted from salivation produced 
by a few grains of blue pill. The patient was unable to 
open the mouth wider than half an inch. Surgical aid 
could give only temporary relief. In another instance, a 
child four years old: the patient, when seen several years 
afterwards, was obliged to suck food through the spaces left 
between the jaws by the loss of the alveolar process.* 

It sometimes happens as a consequence of salivation, that 
adhesions form between the mucous membrane of the lips 

* Pareira's Elements of Materia Medica and Therap. 



110 INFLAMMATION AND ITS CONSEQUENCES. 

and cheek and that of the gums ; very much deforming the 
face and lessening the usefulness of the mouth. 

A great variety of remedies have been suggested and em- 
ployed for the relief of excessive salivation, but there is no 
specific means of relief, no local applications of an irritating 
character can be borne, and no astringent but of the mildest 
quality can be used. Besides demulcent lotions and some 
very mild astringents, such as table tea, we have no topical 
applications to recommend. 

The only rational treatment is to abate the inflammation 
by the use of antiphlogistics, to such extent as the strength 
of the patient will permit. Leeches under the jaws procure 
the greatest relief, and blisters to the throat and opiates are 
useful accessories* 

A form of disease very nearly resembling salivation, oc- 
curs occasionally in children, and sometimes, it is said, even 
in adults. It is ulceration of the inside of the cheek, causing 
gangrene and a copious secretion of fetid saliva. It is called 
cancrum oris. 

This disease is not properly inflammatory, being rather a 
consequence of debility, but lest we should not have an op- 
portunity to describe it hereafter, we will do so now. 

Cancrum oris is a foul fetid ulcer, beginning upon the in- 
side of the cheek and rapidly sloughing through it until it 
opens upon the outside. The gums and alveoli are often se- 
riously involved; the teeth become carious and loose, and 
drop out ; abscesses form in different parts of the mouth and 
make openings for themselves in different directions. The 
progress of the disease is attended by a copious discharge of 
fetid saliva and mucus. Exfoliations of bone are not unfre- 
quent, and extensive sloughing sometimes occurs. 

* It is important to remark that salivation, however severe, does not ne- 
cessarily prove the previous administration of mercury. For some curious 
observations on this subject, see Pareira's Elements of Mat. Med. and The- 
rap. 709. 



INFLAMMATION AND ITS CONSEQUENCES. Ill 

The disease generally occurs in ill-fed children, crowded in 
a hospital or living in low swampy situations. The reme- 
dies must be tonic and invigorating. The principal, are fresh 
air and nutritious diet. The best local applications are di- 
luted mineral acids ; burnt alum ; sul. zinc, tinct. of myrrh, &c. 

The disease is exceedingly rare in our country. 

Syphilis, or the venereal disease, often produces ulcerations 
of the throat, 'which are described in the many books upon 
that particular subject, and require no particular notice here. 

It is proper, however, for Dental Surgeons to know that a 
peculiar and destructive ulceration of the gums, which will 
defy all but specific remedies, sometimes, though very 
rarely, attends Syphilis. As it is impossible to describe 
the peculiar appearance of this ulceration by words only, so 
as to enable the practitioner to detect it upon sight, we refer 
the reader to an excellent delineation of it in Messrs. Carey 
& Hart's Edition of Bayer's Plates, PL xxix., Fig. 15. 

Chronic inflammation of the gums may depend upon any of 
the causes mentioned as productive of acute inflammation. 
It tends rather to ulceration than abscess. 

If there be no specific cause, after the removal of any dead 
teeth, &c, the gums require the aid of astringent and some- 
what stimulating lotions, such as port wine and water, weak 
brandy and water, myrrh, infusion of Peruvian bark, &c. 

There is a common form of disease which is usually called 
scurvy or scorbutus of the gums. This designation, how- 
ever, is very improper ; for scurvy is a constitutional affec- 
tion depending upon long privation of fresh and acescent 
food, aided by the influence of cold, dampness, &c. It is a 
disease peculiar to ships and prisons, and the affection of the 
gums which attends it, is but one among many symptoms 
of the disorder. It is well, therefore, to abandon this term, 
scurvy, as applied to the local disease of the gums in question, 
and following the example of Professor Harris, we will con- 
sider it as an idiopathic inflammation of the gums, attended 



112 INFLAMMATION AND ITS CONSEQUENCES. 

by sponginess of structure; recession of their margins, and, 
frequently, destruction of the alveolar processes. 

When affected by this disease, the gums present a swollen 
appearance. Their color is dark-red or purple; they feel 
elastic under the finger, and when pressed, pus oozes out be- 
tween the -teeth and the margins of the gums, which are 
thickened and detached. The proper tissue of the • gums 
having become to a certain extent fungous, bleeds upon the 
slighest touch, and is very sensitive. 

The disease progresses with more or less rapidity, accord- 
ing to the constitutional health of the patient, and the capa- 
bility of resistance natural to the organs attacked. Some- 
times it is confined to a small portion of the gum, at others, 
it involves the periostea of the fangs and the alveoli, and pre- 
sents a mass of complicated disorder and devastation. A de- 
position of bony matter sometimes takes place in the bottom 
of the sockets, and the teeth are loosened and drop out. 

The treatment of this disease does not differ from that of 
the ordinary inflammatory conditions previously described. 
Indeed it is not specifically different. 

All irritating bodies, such as decayed teeth and roots, must 
be removed; irregularities of denture corrected; tartar also 
taken away; the gums depleted; and after active inflamma- 
tion has subsided, astringent lotions may be used by way of 
correcting the habitual looseness of texture.* 

Caries.^ 

This term has different meanings when applied to the bones 
at large and to the teeth. We will first consider the disease 
of the bones so called. 

Caries in the bones is a disease analogous to ulceration of 

* For a more extended description of this disease and its treatment, than 
is compatible with the scope of this work, see Dr. Harris' Dental Surgery, a 
work which we will take for granted is in the hands of every scientific den- 
tist and every student of dentistry. 

f Kttpsiv — to ahrade. 



IKPLAMMATION AND ITS CONSEQUENCES. 113 

the soft parts, and is very different from necrosis or mortifi- 
cation of these parts. 

The bones are vital organs, supplied with arteries, nerves, 
veins, absorbents and cellular tissue. Like soft parts they 
grow and waste, undergo disease and accomplish reparation. 

The denser the texture of a bone the less liable it is to be 
attacked by caries, and for this reason the bones of children 
are more susceptible of it than those of adults. 

In caries the bone undergoes a change by which its texture 
is softened and broken down ; fungous flesh which bleeds very 
readily grows up in the interstices formed upon the surface 
of the diseased bone ; fetid, dark- colored sanies finds its way to 
the surface through a sinuous channel, and a communication is 
thus formed between the diseased bone and the external parts. 

Caries may nevertheless progress for a long time without 
the formation of an ulcer and discharge of matter ; and these 
results depend more often on necrosis than on caries. 

The treatment of caries consists in the removal of the dis- 
eased part by surgical means, and, as is often necessary, the 
application of the actual cautery upon the new surface. The 
latter means is not absolutely indispensable, the former pro- 
bably is, unless, as frequently happens, the separation of the 
unsound parts may be accomplished by the unaided efforts 
of nature. 

Caries of the teeth is a chemical erosion of those organs 
by the action of the fluids of the mouth, and the accidental 
matters dissolved in them, upon the salts of which the tooth 
is mainly composed. 

It is yet a mooted question whether the teeth are ever sub- 
ject to true caries, such as affects other bony structures. I 
have already remarked that this disease is not apt to occur 
in the denser osseous structures, and the close texture of the 
teeth renders them particularly unlikely to be thus affected. 
Yet it might be too much to say that they are never subject 



,114 INFLAMMATION AND ITS CONSEQUENCES. 

to the active disorganizing process in question. It is certain, 
however, that caries of the teeth, as commonly met with, is 
a mere chemical erosion resulting from the action of acids 
upon the earthy salts which principally compose them. A 
human tooth, inserted as a substitute in another mouth, will 
undergo this change as readily as a natural tooth will do ; 
showing that in this form of destruction the organs assailed 
are passive. 

Mortification or Gangrene. 

These two words are commonly used synonymously to ex- 
press absolute death of a part ; but by some writers the term 
gangrene is restricted to that condition which immediately 
precedes death, and Sphacelus * applied to the latter condition, 
while mortification is a general term covering both conditions. 

According to this use of the terms, gangrene represents the 
condition in which there is a sudden diminution of pain, if it 
has previously existed ; a livid discoloration and subsequent 
yellowish or greenish hue of the part ; a detachment of the 
cuticle with effusion of a turbid fluid beneath it, and a soft- 
ening and crepitation of the part. 

"When the part has become cold, insensible, black, motion- 
less, without circulation, motion and life, the condition is 
called sphacelus. The state of bone analogous to this is called 
necrosis, and the dead part, when detached, a sequestrum.^ 

Mortification may result from any cause which prevents the 
nutrition of a part. Inflammation may so interrupt the cir- 
culation as to cut off the supply of blood, or the state of the 
patient's digestion may not afford a supply of nutrient fluid 
sufficient for those parts, which are least vascular or most 
distant from the heart, and certain obscure changes may take 
place in a part, which may cause it to mortify without the 
precedence of appreciated disease, 

When mortification is consequent upon inflammation, the 

*27r«)catr — to destroy. f Sequestro — I separate. 



INFLAMMATION AND ITS CONSEQUENCES. 115 

quantity of fluids in the part causes a humid state of the 
sphacelus ; where death has taken place from deficiency of 
blood the mortified parts are dry and shrivelled. These oppo 
site conditions have given occasion to the distinction so gene- 
rally recognised between moist and dry gangrene. This dis- 
tinction, however, is not so absolute as to be without excep- 
tion, yet it is correct to a considerable extent. 

Different parts assume different appearances when gangre- 
nous. " Tendons, muscles, nerve and cellular substance, look 
like dirty shreds of wet tow; the skin sometimes looks 
as if it had been destroyed by caustic or the cautery." The 
arches of the mucous membrane are often of a grayish or 
whitish color. Quesnay states that in one case he saw, the 
gangrened parts exhibited a remarkable transparency. The 
black color cannot therefore be considered as characteristic 
of gangrene. It may exist independently of mortification, 
and the latter may exist independently of the other. The 
principal characteristics of gangrene are, 1st. Complete dis- 
organization of the gangrenous part, in which the ele- 
mentary tissue can no longer be distinguished. 2d. Soft- 
ness and flaccidity. 3d. The fetid and characteristic odour 
which it inhales. 4th. The sanies, ichor and fetid gas which 
escape from it. In that variety of gangrene, termed dry, the 
part presents a black color, a hardness sometimes like that of 
wood, and always a complete disorganization of the tissue* 

The treatment of gangrenous parts must be directed to the 
limitation of the mortification, and to the removal of the 
slough. "When a part has become dead, it seems to act as a 
depressing or devitalizing agent upon the surrounding parts, 
and even upon the general system. If the gangrene take 
place in one of the viscera, the patient generally sinks rapidly 
and soon expires. Immediately upon the gangrenous change* 
the pulse becomes soft, weak and frequent, the skin cold, and 

* Chomel, Elements of Gen. Path. 



116 INFLAMMATION AND ITS CONSEQUENCES. 

the nervous system seems to labor under a silent, but deadly 
influence not to be resisted. 

It is difficult to account for this sudden and extraordinary 
result. It is generally supposed that the fluids of the gan- 
grenous part, being absorbed, prove poisonous to life ; but if 
this were the case, similar effects would result from the much 
more extensive mortifications which frequently occur in the 
skin, muscles and bones, without those serious constitutional 
results. The effect must rather be attributed to the power- 
ful sympathy which exists between the viscera and the nerves 
of organic life. 

Where nature makes an effort to check the spread of gan- 
grene, which, except in the instances referred to, she almost al- 
ways does, a red line of inflammation is first drawn around the 
affected part. Ulceration soon takes place along this line, and 
a suppurating furrow separates the dead from the living 
parts. A similar process goes on beneath, and advancing 
granulations gradually push off the gangrenous slough, and 
supply its place with sound flesh. Inflammation and ulcera- 
tion, therefore, are the means employed for the removal of 
dead parts, and for limiting the progress of devastation. 

In order to effect this, it is necessary that the vitality of 
the adjoining parts be sufficient to produce healthy inflam- 
mation, support the suppuration and sustain vigorous granu- 
lations. It is also necessary, that the inflammation in the ad- 
joining parts be not so great as seriously to impede the circu- 
lation in them. 

The surgeon takes his suggestion of remedial treatment 
from these necessary conditions. If the parts adjacent to 
the gangrene be cold and livid, and if they show no disposi- 
tion to throw out the inflammatory cordon sanitaire, he sees 
the necessity of stimulating applications to rouse the torpid 
energies of the threatened parts. Cantharides, turpentine, 
or other remedies of this powerful class will then be put in 






INFLAMMATION AND ITS CONSEQUENCES. 117 

requisition; and should the parts under the slough be 
equally torpid, he will cut through the mortified covering 
and apply his excitants to the flesh beneath. 

Sometimes, though not often, he will find it better to anti- 
cipate the slow process of nature, aud at once remove the 
gangrene by his knife. The latter process is fraught with 
this difficulty, that when the surrounding parts are feeble 
and disposed to gangrene, the use of the knife imparts to 
them no strength while it necessarily inflicts injury. The 
result often is the appearance of the disease in the remain- 
ing parts. 

"When the surrounding .parts manifest more excitement 
than is compatible with their security, depleting and seda- 
tive treatment must be instituted. As a general rule, how- 
ever, this will rarely be required, for the vicinage of gan- 
grene is generally abundantly sedative to the surrounding 
parts. 

Necrosis, or mortification of bone, may take place from 
similar causes to those which produce gangrene of the 
soft parts. As the bones possess less vitality, they are less 
capable of resisting disease, and therefore are more prone to 
die from injuries and internal causes than other parts. 
That they are not more frequently necrosed than they are, 
depends upon their protection from external violence by the 
soft parts, and the fact, that their limited vitality and simple 
functions involve less tendency to disease than is connected 
with the more exquisite organization and complicated func- 
tions of other organs. 

Necrosed bone is thrown off by a process very analogous 
to that which is instituted for the separation of sphacelus. 
Where the mortification is superficial, it is removed by ex- 
foliation; when it is deeper, a persevering effort is made by 
the surrounding bone and soft parts, to detach and expel it 
in the form of splinters, or even of large masses, called se- 
questra. 



118 INFLAMMATION AND ITS CONSEQUENCES. 

Owing to the density of bone and its deep-seated posi- 
tion, this is generally a very slow process, requiring months 
and years for its accomplishment, and often failing alto- 
gether. For after long- continued fruitless efforts to get rid 
of the dead part, nature frequently attempts to supply the 
deficiency caused by its loss and forms new bone around it, 
leaving orifices in this bony case, through which the matter 
may find a vent. When this arrangement has been made, 
the sequestrum cannot be expelled by natural efforts, except 
in a fluid or very comminuted state. It is, therefore, gene- 
rally necessary for the surgeon to cut down to the diseased 
bone and liberate the sequestrum. 

Occasionally, however, nature, though unassisted, will 
accomplish the expulsion of very large sequestra. In one 
recorded case, a piece of bone seven inches long was thus 
expelled: such cases, however, are very rare. 

The presence of the necrosis or caries may be ascertained 
very satisfactorily after the formation of the external ulcer. 
Sometimes the canal will be so straight as to permit a probe 
to reach the diseased part, and when this is not the case the 
presence of an obstinate ulcer, evacuating dark- colored and 
fetid sanies, will generally be sufficient evidence of dis- 
eased bone. 

It is rarely possible to distinguish necrosis from caries, 
until the sequestrum has become so fully detached as to be 
movable. The cure of necrosis as of caries, if procured by 
art, depends upon the removal of the part so diseased. In 
necrosis, the parts surrounding the sequestrum are gene- 
rally in such a state as to return to health after its removal. 
In caries, the surface of the parts exposed by the operation, 
often requires the application of the cautery, as before stated. 

We have already mentioned, that what is called caries of 
the teeth, differs very essentially from the disease of the 
bones, which bears the same name. 






INFLAMMATION AND ITS CONSEQUENCES. 119 

Caries of the bones, as we have seen, is a diseased vital 
action, in which the vessels, &c. are active : caries of the 
teeth is simply a chemical erosion which may be imitated 
upon teeth separated from the month, and afYects dead teeth 
as readily as living ones. 

Caries of the teeth generally, perhaps always, begins upon 
their outer surface, and does not appear to be in any man- 
ner dependent upon disease, except so far as it may be fa- 
vored by an unhealthy structure of the teeth, and a morbid 
condition of the fluids of the mouth. 

In short, caries of the bones is a vital, that of the teeth, a 
chemica] process. 

By instituting a comparison between caries of the teeth 
and that of other bone, it will at once be perceived, that there 
is not the slightest analogy between the disease as it occurs 
in the one and manifests itself in the other. In the former, 
it consists simply in a decomposition of the earthy basis of 
the organs, whereas, in the latter, it is analogous to ulceration 
in soft parts, and constantly discharges a fetid sanies, and fre- 
quently throws out granulations of fungous flesh. These are 
phenomena which dental caries never exhibits, and they estab- 
lish a wide difference between it and the disease as occurring 
in other osseous structures of the body."* 

The treatment of caries belongs to Surgical Dentistry, and 
to works on that subject, and particularly to the excellent 
treatise by Prof. Harris we refer the reader. 

Necrosis may take place in the teeth as in other bones, and 
from a similar cause, — the cessation of circulation in them. 

This may be effected by violence. The teeth, especially 
the anterior ones, are very much exposed to be injured by 
blows or falls, and it sometimes happens, that a shock thus 

* Harris' Dental Surgery, which see, for a thorough examination and ex- 
position of this subject. 



120 INFLAMMATION AND ITS CONSEQUENCES. 

inflicted is sufficient to break up the vascular connections of 
the organ without displacing it from its socket. 

More commonly here, as in other bones, the necrosis takes 
place as a result of inflammation ; the pulp having been de- 
stroyed by this process. 

When a portion of bone dies, the surrounding bone sets 
up a process of removal and reparation. Nothing of this kind 
occurs in the teeth ; partly because the evil is generally shed 
over the whole organ at once, and partly because its low 
vitality does not permit of such effects. 

After necrosis has taken place, the tooth, having become a 
foreign body, produces the usual effect of such causes upon 
the surrounding soft parts. The gums inflame, ulcerate and 
detach themselves from the tooth ; but not being assisted by 
similar processes in the bone, they are unable to remove the 
evil. Chronic disease is, therefore, commonly the conse- 
quence. 

Necrosed teeth lose their color and become dark-brown 
bluish or dingy : sometimes, when presenting this appearance, 
their vitality is not completely destroyed, and therefore they 
may remain in the mouth for years, without provoking the 
disease of the soft parts, which would require the removal of 
the necrosed organs. 

The manufacture of lucifer matches has introduced a new 
cause of necrosis of the jaws. The vapor of the phosphoric 
acid preys upon the periosteum, and induces serious and even 
fatal destruction of the maxillary bones. It is said that this 
is not noticed, except when the teeth are carious. " The dis- 
ease usually begins with moderate periostitis, which thick- 
ens the membrane and incrusts the jaw with new bony forma- 
tions. Then acute inflammation supervenes, the new bone 
exfoliates, the soft parts slough and ulcerate, and necrosis, 
more or less extensively, destroys the jaws."* 

* Miller's Surgery. 



CHAPTEE VII, 



ULCERS. 



An ulcer is a running sore ; or ; in medical language, a solu- 
tion of continuity in a soft part, with, a secreting surface. 

Ulcers present a variety of appearances, depend upon very, 
different causes, and exhibit dissimilar conditions of the parts 
implicated in them. 

A great many attempts have been made to classify ulcers 
Some authors have endeavored to arrange them by their ap- 
parent phenomena, others by their pathological conditions, 
and others by the modes of cure to which they severally 
yield, while some have seized upon accidental modifying 
circumstances as a reason for multiplying subdivisions al- 
ready too numerous. 

It is impossible to systematize in pathological science, so 
as to provide for all the numberless modifications which may 
be produced in disease by the causes which influence vital 
action. We must content ourselves with such an arrange- 
ment as will enable us lucidly to express what we know of 
the subject. Once more we remind our readers that medi- 
cal definitions are not philosophically complete and accu- 
rate. 

An important distinction between ulcers is found in the 
fact that some of them are the result of local injury or dis • 
ease, and not in any manner dependent for their existence 
upon constitutional vice, while with regard to others the con- 
verse is the case ; the local sore being only a consequence of 
constitutional disorder. As the treatment must differ essen- 



122 ULCEES. 

tially in these different cases, it is very important to be able 
to distinguish the one class of ulcers from the other. 

Yet even this distinction, apparently so obvious and pro- 
per, is not without difficulty, for local ulcers sometimes in- 
volve the general health, and are instrumental in setting up 
diseased constitutional action, in which they themselves par- 
ticipate, and, on the other hand, ulcers primarily induced by 
constitutional causes, may continue after the vice of the gene- 
ral system has been corrected. 

The causes of ulcers are various, but can generally be re- 
duced to the following classes : 

1. Predisposing causes. All those conditions of the system 
or of any of its parts, which debilitate structures or so alter 
their vital action as to impede recuperative processes. Fever, 
scrofula, syphilis, and scurvy, are examples of this kind. 

2. Exciting or immediate or local causes; such as wounds, 
bruises, abscess, suppuration, gangrene, abrasion of the skin 
from any cause. 

3. From the combination of these causes. A slight scratch 
or excoriation that in a sound constitution would heal with- 
out any trouble, in a habit tainted with disorders as above 
mentioned, will frequently produce a very disagreeable and 
tedious ulcer.* 

The prognosis of ulcers, must, of course, depend upon the 
results of a full consideration of the causes and conditions in- 
volved in any particular case. The constitution of the pa- 
tient, his age and habits, the situation and duration of the 
sore and its peculiar condition of sensibility, &c, must all 
have due consideration in forming a prognosis. 

It is always proper to attempt the cure of ulcers, except 
such as are of a malignant character, known to be incurable 
through any means yet known to us. 

* Benjamin Bell on Ulcers. 



ULCEKS. 123 

After ulcers have become chronic, it is sometimes danger- 
ous to heal them until we shall have provided an artificial 
drain, by seton or issue. The system having once become 
habituated to the discharge of ever so small a quantity of 
matter, often suffers severely with a kind of 'plethora, if the 
discharge be suddenly stopped. 

The simplest, most practical, and most rational of all the 
classifications of ulcers we have seen, is that adopted long- 
since by Mr. Benjamin Bell, and generally superseded by 
more complicated arrangements, which beget confusion in 
the mind of the student, and are, after all, not more precise 
and accurate than the one for which we have professed our 
preference. 

Mr. Benjamin Bell classifies ulcers as follows: 



LOCAL AND CONSTITUTIONAL. 

1. The venereal, 

2. The scorbutic, 

3. The scrofulous. 



1. The simple purulent, 

2. The simple vitiated, 

3. The fungous, 

4. The sinuous, 

5. The callous, 

6. The carious, 

7. The cancerous, 

8. The cutaneous. 
It is not our purpose to describe in detail the appearance, 

nature, and treatment of each of the kinds of sore above enu- 
merated; but we will confine ourselves to the consideration 
of such as may occur in the mouth, and thus fall under the 
notice and care of the Dental Surgeon. 

The simple purulent ulcer is the simplest form of sore. It 
is always a local affection ; it is attended with little pain, and 
but slight inflammation, and furnishes healthy pus and firm 
granulations. 

A sore of this description needs little or no aid from art, 
but it is important that the student should be well acquainted 



124 ULCEES. 

with its appearance, because other ulcers, of a less simple 
and kindly character, must be brought to this condition be- 
fore ultimate cure. 

The simple purulent ulcer is always produced by some 
local injury, as wounds, burns, &c, happening to persons of 
sound general health. 

In this kind of sores the pus is white and thick ; the gra- 
nulations small, firm, florid, and pointed. As soon as they 
have reached the level of the surrounding parts, those next 
the edges become smooth, and are covered by a whitish pelli- 
cle, or film, which afterwards hardens, advances, and forms 
the permanent covering of the parts previously ulcerated. 
This white, smooth margin, lost in the surrounding skin or 
mucous membrane, is one of the surest characteristics of 
this kind of sore, but it is not infallible ; other qualities 
must be duly considered, before a conclusion is formed. 

Such ulcers require no treatment except to be kept clean, 
and protected from any interference with the natural process 
which is hastening to cure. 

A little dry lint will accomplish all that can be done by 
dressings. A simple purulent ulcer may very readily be 
converted into an angry and obstinate sore by improper lo- 
cal applications, or the occurrence of general constitutional 
disorder, 

We may remark here that no sores are cured by applica- 
tions of any kind; nature only can provide the means by 
which these breaches can be healed. Nothing is more in- 
correct or dangerous than the idea that certain dressings have 
a specific or magical virtue, by which they close wounds and 
cicatrize ulcers. The surgeon may aid nature — he cannot 
supply her place ; and his business is, generally, so far as 
the cure of ulcers is concerned, to aid her in her efforts to 
bring any particular sore into that condition " which natural 
means will suffice to relieve." 






ULCERS. 125 

Simple vitiated ulcer. When, from any of the causes we 
have mentioned, nature fails to produce such a condition of 
ulcer as we have described, in any part which has been 
wounded, or when, from improper dressings, motion, and 
fatigue of the diseased part, or constitutional causes, the 
progress towards cure is arrested, the discharge from a sore 
may present one of the following appearances: 

1st. It may be a thin, limpid, sometimes greenish dis- 
charge, termed sanies. 

2d. A somewhat red-colored, thin, and generally very 
acrid matter, termed ichor. 

3d. A more viscid, glutinous kind of matter, called sordes* 

While discharging matter of a kind like any of these, an 
ulcer will not heal. The granulations become dark, and waste 
away; the matter, especially that called ichor, is very acrid, 
and renders the sore very irritable and painful. It frequent- 
ly excoriates the surrounding parts over which it flows. 

These vitiated ulcers are more apt to occur upon tendi- 
nous and aponeurotic parts, than in situations abounding 
with cellular membrane, owing to the frequent motion of 
these parts, and the continual agitation of the sore. Where- 
ever an ulcer is seated upon a part of this character, abso- 
lute rest is necessary to preserve its simple and convalescent 
character. 

The cure of these ulcers depends principally upon re- 
moving the cause which has operated to change their cha- 
racter for the worse. If the vitiated condition depends upon 
constitutional causes, these must be combated by the means 
found most successful in the practice of general medicine; 
if any local irritant has caused the evil, it must be removed 
as speedily as possible ; if motion of the part has been in- 
dulged, it must be restrained. 

* Benjamin Bell. 



126 ULCEES. 

The local treatment consists in soothing, emollient appli- 
cations, as it has been found that all those means which al- 
lay the pain in such sores, tend also to alter their condition 
to that of the simple purulent ulcer. 

When the sore is seated in the mouth, but little oppor- 
tunity is afforded for local applications. The best, perhaps, 
is warm water, frequently taken into and held in the mouth ; 
or the vapor of hot water received into it repeatedly, and for 
a considerable time. The dentist should look closely in 
such cases for causes of irritation in diseased teeth and fangs, 
and also ascertain whether constitutional causes are inte- 
rested in the production of the troublesome sore. 

The difficulty of protecting ulcers in the mouth from the 
contact of its secretions, and the food and drink, and the im- 
practicability of dressing them with applications elsewhere 
serviceable, should make the dentist extremely cautious lest 
a careless or awkward movement of an instrument in his 
hand should produce a wound and sore extremely painful to 
the patient, and difficult of cure. 

The Callous Ulcer. When ulcers become inactive and sta- 
tionary, rather than progressive, secreting but little, and that 
of a bad quality, and being little sensitive, they are called 
indolent; if, in addition, the edges become hard and thick- 
ened, they are called callous. 

Yery often these callous ulcers are attended with an en- 
larged condition of the veins of the part, which is called va- 
ricose. This condition of the veins is very embarrassing to 
the surgeon, and sometimes produces fatal hemorrhage. 

Callous ulcers are most common upon the extremities, 
and owing to the mechanical difficulty in the return of blood 
from these parts, they are, in these situations, most frequent- 
ly attended with varicose veins. The callous condition of 
ulcers is the consequence of neglect and bad management. 



ULCEES. 127 

Their cure consists in restoring them as soon as possible 
to the condition of a simple purulent sore. 

When the sore is merely indolent, the surface is jet struc- 
turally capable of producing healthy granulations. All that 
is needed is to bring it to the right suppurative action. 
Sometimes the inactivity of the sore results from irritation, 
either from local or constitutional causes. In such cases it 
must be soothed by position and soft sedative applications, 
as warm poultices, or the constitutional impediment to the 
local action must be removed. 

When the indolence is not connected with irritation, gently 
stimulating means can be used to rouse the vessels to greater 
activity ; in short, to increase the inflammation. When the 
surface is callous, it must be removed, and this is best effected 
by lunar caustic. (Nit. Argenti.) A blister over the ulcer 
is not unfrequently resorted to, but it is less manageable 
than the caustic. 

Mechanical pressure is very useful in the management of 
these sores, particularly where they are seated on the legs 

When the margin is not elevated and hard, a common 
roller passed around the entire limb to a point considerably 
above the sore, will be sufficients When the edges are ele- 
vated and hard, strips of adhesive plaster carried tightly 
across from edge to edge, in addition to the roller, create ab- 
sorption of the indurated parts, and excite active suppura- 
tion. 

Whatever means are used, the object is to convert the 
sore into the simple purulent ulcer, to which condition all 
must be brought in their way to convalescence. 

The presence of some foreign matter, or decaying portion 
of bone, or tendon or fascia, or the passage of some excretion 
caused to flow from its natural through the artificial chan- 
nel. 

Fungous Ulcers. When granulations are large and pale, 



128 ULCEES. 

grow rapidly and rise above the level of the surrounding 
parts, bleed freely upon touch or slight pressure, and make 
no attempt at cicatrization, they are called fungous or proud 
Sesh. Generally they are soft and spongy, but by very 
long continuance they may acquire considerable hardness. 
Fungus is not uniformly sensitive ; generally it is not at all 
remarkable in this respect; occasionally, however, it is very 
sensitive. It is but imperfect granulation, and may arise 
from any cause which tends to interrupt the convalescence 
of an ulcer. Long-continued inflammation of cellular struc- 
tures and caries of the bones are very apt to be attended by 
fungus. It sometimes occurs in ulcers of young and vigorous 
subjects merely as a kind of exuberant growth, which can 
hardly be considered as giving an unfavorable appearance 
to a sore, as it is readily removed by mild escharotics. 

Where fungus depends upon a mere defect of action of 
the vessels of a part, and not upon the presence of any irri- 
tating cause vitiating the character of the ulcer, it may be 
destroyed very readily by sprinkling upon it some burnt 
alum, or touching it with lunar caustic. Fungus has not 
sufficient vitality to resist the impression made by agents 
of this class, and generally the application of the escharotic 
will excite the surface of the ulcer sufficiently to cause the 
growth of firmer granulations. 

The Sinuous Ulcer. — This name is given to a sore commu- 
nicating with long and narrow canals, penetrating the cellu- 
lar membrane and running irregularly under the skin or be- 
tween the muscles. These sinuses generally have more than 
one opening through which pus is discharged. 

Originally they are the artificial channels through which 
the contents of abscesses or the fluids produced from carious 
parts escape from parts deeply seated or so placed as to be 
unable to pass off matter in a straight line; but the sides of 
the canals themselves becoming inflamed, and secreting mat- 



ULCEES. 129 

ter, the whole presents the appearance of an irregular ulcer, 
connected with some primary source of matter, and forming 
openings wherever the nature of the part causes a determina- 
tion of matter to the surface. 

Should the sinus remain for a long time without cure, its 
sides and the edges of its orifices become hard, and it is then 
called a fistula.* 

The cause of sinuses is the want of a free passage for mat- 
ter, which seeking the most dependent point, readily pene- 
trates the yielding texture of the cellular membrane and ulti- 
mately produces ulceration at a point distant from its source. 

The cure of these sinuous ulcers depends upon making a 
free passage for the matter in a direct line from its source, 
and then bringing the edges of the canals together and 
causing them to unite, or removing the foreign matter, or 
restoring the wandering excretion to its former, or, at least, 
more convenient channel. 

After this, pressure should be used upon the sinus; if that 
should fail, stimulating or caustic applications may be used 
with advantage. Sometimes it is necessary to lay open these 
tortuous canals to the primary abscess, a process which at 
once gives free escape to the matter, and by exposing the 
sides of the sore to the influence of the air and proper, me- 
dicinal applications, generally causes a wound which readily 
heals from the bottom with healthy granulations. 

Sinuses situated in the mouth should always be treated 
in this way, unless they are connected with diseased bones 
or teeth, or are so situated as to make the free use of the 
knife dangerous. 

''Where the sinus is both deep and extensive, it is not 
necessary to incise its whole space. The inner half will pro- 
bably follow the curative processes of the outer." (Miller.) 

* Fistula — a pipe. 



130 ULCEES. 

Carious Ulcers are those which are connected with caries 
or necrosis of bony structures. They are often sinuous, but 
may be seated immediately upon the caries which causes 
them. 

The discharge from carious ulcers differs from good pus. 
It is thinner and fetid, and at last becomes blackish, and of- 
ten very acrid and irritating. Mr. Bell thought that the 
fetor of carious ulcers always afforded a sufficient means of 
diagnosis. 

The surfaces of carious ulcers are usually softer and more 
flabby than natural; and instead of a florid red, they have 
rather a dark brown with somewhat of a glassy complex- 
ion. 

The granulations generally grow rapidly, but are exube- 
rant and fungoid. Should the orifice heal either by the ef- 
forts of nature or the appliances of art, the apparent cure is 
of short duration, for the pent-up matter soon finds another 
vent and produces another ulcer. When a probe is pushed 
dow nto the bottom of a carious ulcer, it generally encoun- 
ters a roughness of the surface of the bone, which plainly 
indicates its eroded condition. 

When obstinate sinuses are observed in the gums, dis- 
charging fetid matter, and containing fungous granulations, 
we may always be assured that the cause is to be found in 
the presence of some decayed tooth or root, or to caries of 
the alveolus, jaw or some other bony structure. 

As a carious ulcer is nothing more than an accident at- 
tending caries, the treatment of it must always be secondary 
to that of the disease which produces it. The removal of 
the carious or necrosed part, and the employment of the 
means which will best prevent a return of it, are to be re- 
garded as the proper means of curing the carious ulcer- 
When the caries is seated in the cancellated structure of 
bone, it can only be thoroughly eradicated by the terrible 



ULCEES. 131 

energy of fire, and the actual cautery must sweep over the 
diseased surface and rouse it to the exertion of its vitality. 
When a tooth is the subject of caries, no such frightful treat- 
ment is necessary. The tooth being passive in the matter, and 
being acted upon by chemical agents only, all that is required 
is to remove the caries and interpose between the fluids of 
the mouth and the parts of the tooth thus exposed, a bar- 
rier which must be impenetrable to the action of the fluids 
which caused so much mischief. The only substance by 
which a cavity in a tooth can be successfully filled is gold, 
as it only, of all the metals, possesses both the physical and 
chemical qualities necessary to the purpose. If gold cannot 
be used, tin, though far inferior, is the best substitute. All 
the mercurial amalgams are exceedingly deleterious, both 
locally and constitutionally, and ought never to be used as 
dental fillings. 

The Cancerous Ulcer — Cancer, or Carcinoma. This terri- 
ble affection occurs under two forms, called occult and open, 
or scirrhous and ulcerative. The former variety generally, 
though not always, precedes the latter, and presents itself in 
the form of a hard, dense tumor, of slow growth, generally 
seated in a glandular structure^ at first, in most cases, nearly 
insensible, and subsequently causing very sharp darting or 
burning pain, or twinges, which radiate from the scirrhus 
as from a centre. As the disease progresses, the skin ad- 
heres to the tumor, corrugates or puckers, changes color, 
becoming of a livid or leaden hue, then ulcerates and ushers 
in the second stage of the disease, the open or ulcerating 
cancer. 

The ulcer thus produced is exceedingly painful and irri- 
table. It discharges a thin fetid ichor, sometimes very exco- 
riating. Its edges are hard and irregular, reversed and con- 
torted. Its surface is generally irregular, showing depres- 
sions or excavations. The sore manifests no tendency to 



132 ULCEKS. 

form healthy granulations, but spreads among the surround- 
ing tissues which successively harden and ulcerate, and be- 
come cancerous. The lymphatics propagate the disease to 
the nearest glands, which are found swollen and indurated, 
and often ulcerated. 

The pain of cancer is a burning or scalding sensation, and 
generally exhausts and destroys the patient long before the 
devastation of parts can interfere seriously with the func- 
tions of life. 

As blood vessels are destroyed in the progress of the dis- 
ease, bleeding, more or less profuse, occurs. 

Cancer, however, presents various appearances. We 
have seen it occur without preceding scirrhus, present an 
equal smooth surface with little secretion ; and many other 
appearances of this ulcer have been observed, as it has been 
modified by accidental circumstances. 

The characteristics of cancer may be considered to be an 
irregular, phagedenic sore, with hard reversed edges, ex- 
ceedingly irritable under all common dressings, and causing 
a burning pain. When such a sore has resisted the treat- 
ment which is s found to be successful in ordinary irritable 
ulcers, and especially when it is seated in a glandular part 
and follows scirrhus, there can be no doubt of its malig- 
nant character. 

Cancer, in all its stages, is altogether intractable to any 
treatment which has yet been devised, and all but the most 
soothing applications are found to accelerate its^ progress 
and add to the intolerable acuteness of its pain. 

The only mode of cure now attempted is thorough extirpa- 
tion, and this is confined almost entirely to the latent or 
scirrhous state. The open cancerous sore rarely yields even 
to surgical remedies. It is even a mooted question whether 
the removal of scirrhous tumors is advantageous. Some 
surgeons contend that where true scirrhus is removed, can- 



ULCEES. 133 

cer soon makes its appearance elsewhere, often in a more 
malignant form and in a worse location, and that the life of 
the patient is often shortened by the painful operation en- 
dured in the hope of cure. 

It is not by any means easy to settle this question. Sur- 
geons are in the habit of removing all chronic tumors which 
are hard and painful, whether they present decidedly carci- 
nomatous symptoms or not. Many of these are probably 
not cancerous, yet the operations by which they have been 
removed enter into the statistics of cancerous extirpation. 

Where but one possible hope is left, we should be very 
careful not to extinguish it, and we therefore recommend 
the exsection of scirrhous tumors. To be successful, however, 
the operation must be performed before the disease has 
manifested activity by changing the surrounding parts into 
its own peculiar texture. 

Even when the cancer has reached the condition of a foul, 
wasting, and tormenting sore, extirpation by the knife will 
sometimes be desirable, for the temporary relief it may give 
the victim. Six years ago, a neighbor of ours was re- 
lieved of a sore of this kind by amputation of the arm. 
Since that time, he has been able to attend to the duties of 
life, the cancer has not reappeared in a decided form, and as 
he is an elderly man, and carcinoma proceeds slowly in old 
persons, he may escape a return of the disease, at least, in 
the aggravated character in which it existed before the am- 
putation. 

There is a form of carcinoma called " medullary," " spon- 
goid," or "fungus nematodes," in which the tumor is elas- 
tic, grows more rapidly, and after ulceration presents a pro- 
truding fungous appearance, with a strong tendency to 
wasting hemorrhages. This kind of cancer is the result of a 
more thorough pervasion of the constitutional disease, and 



134 ULCERS. 

less power of resistance to the unnatural growth. It is 
rapidly fatal, and if excised commonly reappears, often in 
some vital place! 

The cause of cancer is also a matter of controversy. It is 
often excited by a wound, especially a bruise or pinch; but 
this can only occur where there is a constitutional tendency 
to the affection. On the other hand it frequently appears 
without any exciting cause. Some writers, in view of these 
facts, contend that cancer is primarily a local affection, having 
a strong tendency to infect the whole system with its own 
poison. They, therefore, very rationally conclude that if it 
be extirpated in its latent state, the patient may be entirely 
relieved from it. Others believe that carcinoma is a consti- 
tutional disease, manifesting itself in local changes of the 
kind described; that it is, therefore, useless to remove the 
local effect, and the constitutional cause being beyond our 
control, they prefer, in the present state of medical science, 
to refrain from all attempts at cure of the disease. 

On each side of the question are presented observations 
and pathological demonstrations, and authoritative names, 
and without troubling our readers with a recapitulation of 
the facts and arguments brought to bear upon this subject, 
we will content ourselves with suggesting the practical in- 
ference which seems most rational upon the whole ; which is, 
that eradication of scirrhus may be attempted with good 
hope, though not with certainty of success; that the exci- 
sion of open cancer will be an experiment very doubtful, 
yet if the reports of surgeons are to be believed, not abso- 
lutely hopeless; and finally, that under all circumstances 
the operator must be prepared for a recurrence of the dis- 
ease. 

Many specifics have been suggested for the cure of cancer, 
and many nostrums are yet vended for the purpose of curing 
these sores. For the most part these are useless nostrums, 



ULCEES. 135 

which have not the least control over cancerous degenera- 
tion. Some of them are caustic applications, which actually 
extirpate the diseased part, and are as useful as excision 
would be. In soma cases, caustic has the advantage over 
the knife, and probably has been too generally abandoned 
by surgeons. Cancer doctors often get reputation by at 
least temporarily relieving patients abandoned to their fate 
by scientific practitioners. To be sure, the empirics in 
their ignorance of the distinction between malignant and 
analogous sores, often apply their escharotics where they do, 
great mischief, but these blunders do not go before the pub- 
lic, while apparent cures are trumpeted throughout the land. 
One young lady, whom we knew, was killed by some appli- 
cation of the kind, supposed to be an arsenical paste, to a 
benign ulcer. 

Cancer sometimes attacks the tongue. We saw a case of 
this kind, which seemed to have been provoked by the 
abrasion of the organ against fractured teeth. The sides of 
the tongue presented a jagged edge, which gave out sanious 
matter. The whole body of the organ was scirrhous, and 
the neighboring glands manifested a similar condition. 

A cause so slight as the retention in the mouth of a bro- 
ken or eroded tooth, seems, in this case, to have been suffi- 
cient to excite this fearful malady, in a part, too, where the 
greatest possible inconvenience and distress must result from 
its presence. 

The lips, too, are very frequently the seat of cancer, and 
the dentist should be careful not to wound these very vas- 
cular and sensitive parts by careless or awkward handling 
of the sharp instruments he wields. 

As the several varieties of cutaneous ulcer are not likely 
to require treatment from the Dental Surgeon, we will not 
consider them, but refer the curious reader to the several 



136 ULCERS. 

surgical works in which they are accurately described and 
their proper treatment pointed out. 

ULCERS DEPENDENT UPON CONSTITUTIONAL CAUSE. 

^Venereal or Syphilitic Ulcers. — Impure sexual intercourse 
has engendered a poison which is capable of producing local 
and constitutional disease of a distressing and dangerous 
character. With the consideration of local or primary sy- 
philis we have nothing to do, but as the secondary or con- 
stitutional disorder develops itself in the structures of the 
mouth, it is necessary that the well-instructed dentist shall 
be prepared to detect and treat it, when thus manifested. 

Syphilis usually presents itself in the form of ulcers, 
which are called chancres — it also causes cutaneous erup- 
tions, swelling of glands and disease of the periosteum, fas- 
cia and bones. 

The ulcers vary considerably. Generally they are remark- 
able for their hardened base, feeling like cartilage under 
the skin ; the borders are red and sharp, the bottom gray- 
ish, and the sores painful, and not tending to heal. 

In the throat, tonsils and mouth, the disease generally 
shows itself at once, without much previous tumefaction, so 
that the tonsils are not much enlarged; for when the vene- 
real inflammation attacks these parts, it appears to be always 
upon the surface, and it very soon terminates in an ulcer. 

These ulcers of the throat are to be carefully distin- 
guished from all others of the same parts. The disease in the 
throat is uniformly ulcerative ; this being the first appear- 
ance of disease in that part.* 

The syphilitic ulcer always begins superficially, and is not 
preceded by observable, or at least, by any notable degree 
of inflammation. This fact will be sufficient to distinguish 

* Hunter on the Venereal Disease. 



ULCEUS. 137 

these sores from the ordinary open abscess of the sup- 
purating tonsil. 

There is also an indolent swelling of the tonsil accompa- 
nied by an exudation of lymph, which at first sight might 
be mistaken for an ulcer, and indeed such exudations, when 
they accompany scarlet fever, are often miscalled sloughs. 
They may be detached from the subjacent membrane, which 
is found unbroken. 

There is another complaint of those parts often mistaken 
for venereal, which is an ulcerous excoriation running along 
the surface of the parts, becoming very broad and some- 
times foul, having a regular termination, but never going 
deep into the surface of the parts. Mr. Hunter says that 
there is no part of the inside of the mouth exempted from 
this ulcerous excoriation, but it occurs most frequently 
about the root of the uvula, and spreads forward along the 
soft palate. 

The same writer observes that the true venereal ulcer in 
the throat is a "fair loss of substance, part being dug out as 
it were from the body of the tonsil with a determined edge, 
and is commonly very foul, having thick white matter ad- 
hering to it like a slough, which cannot be washed away." 
These ulcers never heal spontaneously, and generally spread 
rapidly. When the sores are seated upon the pharynx, 
they produce great distress in deglutition, cough and puri- 
form expectoration, rapid sloughing of the soft parts, ex- 
posing the bones and destroying them even as far as the ver- 
tebra by caries. The palate is frequently destroyed, throw- 
ing the nose and mouth into one cavity, preventing distinct 
speech, and causing great discomfort and distress. The den- 
tist will often be required to supply this serious loss of bone 
by an artificial substitute. 

''At other times, especially in cases of long standing, these 
10 



138 ULCEKS. 

sores extend not by sloughing, but by rapid ulceration. The 
aspect is less formidable, but its progress is scarcely less de- 
structive. This variety is most commonly seen on the soft 
palate. The surface is foul, but the slough which occupies it 
is of little depth. The sore is edged by a very narrow fringe 
of yellowish slough, and beyond this for the extent of a 
quarter of an inch, there is an inflamed margin of a deep 
crimson color; but there is not much general sloughing of 
the surrounding parts. Yet the sore extends daily with ex- 
traordinary rapidity. The substance of the part seems to 
melt away under the ulceration, and the greater part or the 
whole of the soft palate, is often destroyed before it can be 
arrested, though no distinct slough can be seen to separate 
through the whole of its course."* 

Phagedenic venereal ulcers, like cancerous sores, have 
thickened edges; a characteristic rather of the unhealthy 
character and spreading tendency, than of any specific qua- 
lity of the sore itself. 

There are several kinds of venereal affections observed 
in the bones. The periosteum may be thickened and in- 
flamed. This is a very p'ainful affection, the pain being 
greater at night; and may be mistaken for rheumatism, 
when the bone is so deeply seated as to prevent the distinct 
feeling of the swelling. This periosteal disease generally ends 
in permanent enlargement of the bony structure from depo- 
sition of bony matter. Sometimes the periosteum suppu- 
rates and causes exfoliation of the bone. 

Caries of the bone frequently commences in the cancellous 
structure, and gradually perforates the external plate, and 
then appears as a soft tumor, which may be seen and felt 
externally. If this tumor is laid open, a glairy fluid is eva- 
cuated; the periosteum is found to be somewhat thickened, 

* Babington. 



ULCERS. 139 

and the bone beneath is denuded, and in the centre of the 
denuded part, is found a small hole which perforates the 
cortical plate and communicates with the interior of the 
bone. This affection is very common in the skull, and may 
be seen in the tibia, jaw and ulna. In its worst forms, it con- 
stitutes the worm-eaten caries.* 

In determining whether a sore in the throat or a caries of 
the bones be syphilitic, it is absolutely necessary that the ob- 
server shall obtain all the collateral information which may 
aid the diagnosis ; for it is often impossible to decide posi- 
tively from the mere appearance of the ulcer, whether it be 
venereal or not. 

Very often cutaneous eruptions of a syphilitic character 
attend the venereal sore throat, and the presence of such 
eruptions would be sufficient to decide a doubtful case. 

Unfortunately, however, it is not easy to detect with cer- 
tainty all forms of syphilitic eruption; yet, "when suspicion 
is aroused by the appearance of the throat, and corroborated 
by that of the sMn, or vice versa, there must be extraordi- 
nary reasons for inferring the cause not to be venereal. 

Syphilitic eruptions may be tubercular. That is, they 
may appear in the form of hard lumps, covered by red in- 
flamed skin, and often by dead cuticle. These often ulcerate 
and leave behind them a peculiar copper-colored blotch. 

Another form of syphilitic eruption, is that of small red 
acuminated pimples, sometimes scattered regularly over the 
surface, at others arrayed in groups. 

Scaly eruptions are also common, and sometimes a pus- 
tular affection attended with a large, hard, conical scab or 
crust (rupia) is observed. These may all be due to other 
causes, but when occurring together with a suspicious sore 
throat, they very much strengthen the probability of vene- 
real origin. 

* Babington. 



140 ULCEES. 

Mr. Hunter says, when syphilis attacks the tongue, it 
sometimes produces a thickening or hardness in the part ; 
but this is not always the case, for it very often ulcerates as 
do the other parts of the mouth. 

If the character of the disease be clearly venereal, or if it 
be probably so, it is important that proper remedies be at 
once administered, for when the virus has become so gene- 
rally diffused, as to produce the remote symptoms observed 
by the dentist, the life of the patient is in imminent peril. 

There has been much controversy as to the means of curing 
syphilis, one party contending for the use of mercurial means, 
and the other denying the necessity of these medicines. 

Without^pretending to any claim to decide a question so 
ably supported on either side, we will briefly remark, that 
mercury will certainly cure the disease, except in a few un- 
common cases, where it exists in a kind of combination with 
scrofula; and secondly, that mercury will do this without 
injury to the patient, and generally with as little inconve- 
nience as can attend the use of less certain remedies. With- 
out hesitation, therefore, we recommend its use; especially, 
in constitutional or secondary syphilis, where no time must 
be lost, and no risks must be run. 

As to the particular preparation of mercury most proper 
for the purpose, there also is difference of opinion. As a ge- 
neral rule, however, we prefer the proto-chloride or calo- 
mel to any other preparation. It is more certain than blue 
pill, and perhaps than any other mercurial medicine, and can 
be used with more safety than the deuto-chloride (corrosive 
sublimate.) Our common practice is to give a grain of calo- 
mel, to which is added one-twelfth of a grain of opium, night 
and morning, until the ulcer disappears or the gums get sore. 
It is rarely necessary to produce salivation — a mere tender- 
ness of the mouth will generally indicate the predominance 



ULCERS. 141 

of mercurialization in the system, and be attended by heal- 
ing of the venereal sores, and disappearing of other symp- 
toms of that disorder. 

Corrosive Sublimate in the dose of a twelfth part of a 
grain three times a day will often succeed ; and, in secondary 
syphilis, is thought by some to be superior to calomel. 

When calomel acts too freely upon the bowels, as it some- 
times does, even when administered together with as much 
opium, as it is prudent to give, corrosive sublimate or blue 
pill may be tried. Should these purge also, resort must be 
had to inunction; the patient being rubbed with mercurial 
ointment until his mouth begins to acknowledge the mercu- 
rial influence. When scrofula exists in union with syphilis, 
the iodide of mercury may be used. 

Scorbutic Ulcers. — Scorbutus is a barbarous half Latin 
name, given by medical writers to scurvy, a constitutional 
affection depending upon privation of vegetable food, under 
circumstances calculated to weaken the energies of the sys- 
tem, and which was long a terrible scourge to seamen, soldiers 
and the inmates of prisons. It has frequently been con- 
founded with other affections, a mistake which has led to se- 
rious consequences. In the year 1700, the celebrated Boer- 
haave treated with mercury four hundred soldiers thus af- 
fected, and killed them all. 

The term scurvy, is applied to sponginess and ulceration 
of the gums from any cause, but this i#an impropriety. 
Scorbutus, or true scurvy, is always a constitutional affection, 
never occurs when patients have lived upon diet sufficiently 
vegetable, and, in short, can only be expected to occur in 
ships, camps or prisons : happily since its character has be- 
come known, it is rarely seen now, even in these places. 

As it would be of little use to our readers, we will not in- 
troduce here a full discussion of this subject, which has 
ceased to be of much interest, even to the general practi- 



142 ULCERS. 

tioner; but will content ourselves with a very few remarks 
upon it, referring those who may be curious to know more 
of this subject to a very interesting article upon it in the Cy- 
clopaedia of Practical Medicine, written by Mr. Kerr. 

Scurvy is a general disease characterized by debility, foe- 
tor of the breath, sponginess and turgidity of the gums, livid 
subcutaneous spots, particularly of the roots of the hairs, 
ecchymoses, spontaneous hemorrhages and frequent contrac- 
tion of the limbs. 

The face becomes bloated early in the disease, and the lips 
are of a pale greenish hue. The countenance looks sad ; the 
patient complains of extraordinary lassitude, and becomes 
breathless after slight exertion. The gums soon become 
swollen, itch and bleed upon touch; they are deep red, soft 
and spongy : soon fungous and putrid. Bleeding occurs fre- 
quently from the mouth and other parts, and the breath is 
very offensive. The skin is usually smooth and shining, 
with a suffusion of black or livid spots. Old wounds or sores 
break out afresh, and ulcers frequently occur. 

These sores secrete a thin, fetid sanious fluid ; their edges 
are generally livid and puffed up ; a coagulum soon forms, 
which with great difficulty can be wiped away or separated 
from the subjacent parts/ These are soft, spongy and putrid.* 
A soft, bloody fungus, of considerable size, soon rises from 
the ulcer. When scurvy approaches its fatal termination, 
the livid and painful swellings break, and assume the fungous 
appearance characteristic of scorbutic ulcers. The hemor- 
rhage becomes more profuse and general; the increasing 
dyspnoea is accompanied in some cases with pain under the 
sternum, but more frequently in one of the sides. In others, 
however, without any complaint of pain, the respiration be- 
comes suddenly quick and laborious, and death unexpect- 
edly puts a period to the disease. 

* Cyclop. Prac. Med. 



ULCEES. 143 

The prevention and cure of scurvy consist simply in pro- 
viding a proper vegetable diet, and keeping the patient warm 
and dry. Where this cannot be done, as is the case at sea, 
the purpose can be effected by administering lemon juice 
freely, and making the men as comfortable as possible. Me- 
dicine has little to do in the matter, though it may render 
occasional aid. It is always important to distinguish the 
symptoms of scurvy from those of other diseases ; fortunately 
there is no longer much clanger of mistakes in this respect. 
The subject does not belong to practical dentistry, though 
the disease of the gums connected with it makes it proper for 
us to mention it ; our chief purpose in doing so, however, is 
that our readers may have a proper knowledge of the mean- 
ing of a word which is continually misused by dentists, by 
applying it to a local fungous affection. 

Scrofulous Ulcer. — Scrofula. This word is derived from 
the Latin word Scrofa, a hog — why, it is not easy to per- 
ceive ; but it is singular that the corresponding Greek word 
is also derived from a word (p^ooc) signifying a hog. 

Whether those who originally described the disease were 
aware that swine are subject to it, or whether, as is most 
probable, they intended to portray the dirty appearance of 
those afflicted by it, we have no means of determining. 
Scrofula is also known as Struma, and the word Strumous 
is frequently used instead of Scrofulous. 

Scrofulous tumors and ulcerations are also vulgarly called 
King's Evil, from the loyal superstition which for many years 
attributed to the touch of a sovereign the miraculous power 
to heal the disease. Multitudes of cases were touched by the 
monarchs of England, from Edward the Confessor to Queen 
Anne. A similar practice existed in France. 

Scrofula is a constitutional disorder which manifests itself 
in a great variety of local affections, and is among the most 
distressing, and in some of its forms, the most fatal of all the 
ills that flesh is heir to. 



144 ULCEES. 

The pathology of scrofula is not well understood. It seems 
to affect particularly the' lymphatic system; the glands, 
especially the subcutaneous and mesenteric, being most fre- 
quently the parts which first manifest the local influence of 
the constitutional vice. Yery often, however, its ravages 
are confined to internal organs. The lungs are especially 
liable to be affected by it, assuming that well known and so 
far incurable diseased condition, which is called phthisis* or 
pulmonary consumption. 

Although persons of all temperaments are subject to scro- 
fula, yet those who possess what is called the lymphatic tem- 
perament, are much more liable to it than others ; and as this 
system is predominant in children and women, they are more 
exposed to scrofula than adults and men. 

Yet men are by no means exempt, but those of the male 
sex in whom the lymphatic temperament predominates, are 
most liable to it. 

It is common to distinguish the scrofulous disposition by 
certain external marks which doubtless indicate, with con- 
siderable accuracy, the presence of the constitutional vice. 
These appearances, from the strong disposition to phthisis 
which they manifest, are frequently called "consumptive." 

These marks are a fine white skin; light hair; rounded 
plump figure ; delicate complexion, with rosy cheeks ; large 
lips; large lower jaw; yellowish teeth, or teeth, whatever 
their color, which are soft and easily attacked by caries; a 
large head ; straight and narrow chest ; large abdomen, -end 
soft and flabby flesh. Persons presenting these external ap- 
pearances are generally amiable, and often very sprightly 

Phthisis, from <p9uce— I consume — Consumption. There are several chronic , 
diseases of the lungs, which are vulgarly known as consumption. Most of 
these are inflammatory affections and their consequences. Phthisis, or con- 
sumption proper, is an entirely different disorder in its cause and character. 
It is, with few exceptions, incurable from the commencement. The inflam- 
matory affections are all curable, if promptly and rightly treated. 



ULCEES. 145 

and intelligent, and among them are found the loveliest and 
most attractive of the female sex. 

The strumous diathesis is exhibited in another class of 
persons, very differently. In these the complexion is dark, 
the skin harsh and the habit indolent ; the countenance is 
swollen and pasty, and all the functions of the body are slug- 
gish and imperfect ; the nervous energy is feeble ; the feelings 
are obtuse, and the moral and intellectual powers occupy a 
very low rank. Scrofulous cases of this character are not 
by any means uncommon in Britain or the United States, 
although far more rare than the other variety, but extreme 
instances are frequent in some districts of Switzerland and 
France ; and in these, human nature appears reduced almost 
to the level of the brute creation, assuming forms which 
awaken feelings of humiliation and disgust.* 

Appearances such as described as characteristic of either of 
the two classes of scrofulous subjects, are not necessary to 
the development of scrofula ; but when these marks present 
themselves, nothing but the action of circumstances most fa- 
vorable to counteract the threatened evil, can prevent its ap- 
pearance. 

Scrofula is the consequence of damp, cold climates, bad 
diet, and want of exercise and fresh air. These circum- 
stances, when combined, may engender the disease in any 
child, but in most cases it is hereditary, being transmitted 
from the parent ; whole families being frequently destroyed 
by this fatal legacy. In one recorded instance, in which the 
father and mother were both strumous, eight children out of 
nine died in childhood of scrofulous affections. 

The scrofulous disease manifests itself in a variety of ways. 
In glandular swellings, sluggish ulcers, distorted bones, cu- 
taneous eruptions ; but the most common and the most cha- 

* Cumin. 



146 ULCEES. 

racteristic attendant upon scrofula, is the production of a soft 
cheesy, unorganized matter, which is found mixed with the 
pus of abscesses, or deposited in rounded masses of different 
degrees of firmness, and of various sizes, called tuberculous 
matter. Sometimes this is enclosed in cysts, sometimes dif- 
fused throughout a part, and sometimes it is found in the na- 
tural canals or cavities of the body. To the depositions of 
this matter and the irritation and inflammation which it pro- 
duces, are due the most serious consequences of scrofula. 

Scrofulous ulcers are generally consequent upon tumors 
of the same character. These, after having been indolent 
for a considerable time, at last ulcerate and discharge their 
softened contents. Instead of healing, the orifice enlarges 
and an ulcer is established, discharging a thin glutinous 
fluid, occasionally intermixed with the peculiar cheesy or 
curdy substance already described. 

Commonly, scrofulous sores are not painful; occasionally 
they are so. The skin around them is livid, and slowly ul- 
cerates ; the granulations are flabby and pale, and their mar- 
gins are usually overlapped by the thin unhealthy-looking 
skin. The matter often hardens about the sore, and presents 
a disgusting appearance. The ulcer heals slowly, and the ci- 
catrix is irregular, puckered and wrinkled, " with small por- 
tions of projecting skin and even complete bridges, admitting 
a probe to pass beneath them; features by which their ori- 
gin, long after a cure, may be readily discovered." 

As one ulcer heals, another is often ready to break out, 
and the patient is gradually debilitated and worn down by 
the incessant irritation and drain. Sometimes the disease 
manifests itself in a vital organ, and by speedy death curtails 
the sufferings of the patient. 

To scrofula seems properly to belong a very serious ulcer- 
ation of the lips, nose, &c, which is called lupus, or nolle me 



ULCEES. 147 

This disease commonly commences by the appearance of 
a hard, livid tubercle, which, after being indolent for a longer 
or shorter time, ulcerates, and produces ichorous, wasting, 
ill-conditioned sores, which, in some instances, (lupus exe- 
dens,) rapidly destroy the adjacent parts; in other cases, lu- 
pus induces a sort of hypertrophy of the skin. Sometimes 
the first appearance of the disease is a mere violet red color, 
tending rapidly to ulcerate and destroy the surrounding 
parts. 

The tonsils of scrofulous persons are very prone to chronic, 
indolent swellings, which, upon slight provocation, take on 
acute inflammation. The glands in the neck, and the sub- 
lingual and submaxillary glands, are often affected by scro- 
fula; forming hard, painless, indolent tumors, which some- 
times suppurate, causing intractable ulcers, which, after 
pouring out the glutinous and flocculent matter peculiar to 
this kind of sores, heal with the irregular puckered, ugly ci- 
catrix before described. 

Dr. Cumin says that scrofula occasionally attacks the 
tongue. It sometimes assumes the form of aphthous ulcera- 
tions, and fissures of the margin, but its most characteristic 
features are small knots or nodules, superficially imbedded 
in the substance of the organ, varying in size from that of a 
small shot to that of a horse bean. They cause no uneasi- 
ness, unless tv hen firmly pressed, and then the pain is slight 
and pricking. The mucous membrane covering them, is 
red and prominent, and soon breaks in the centre, giving 
rise to an ulcer, which spreads and destroys by sloughy ero- 
sion, with much pain, profuse salivation, furred tongue, and 
fetid breath. The ulcers, under proper treatment, become 
clean, contract and heal; but the hardness remains; fresh 
nodules form in other parts of the organ, and the same train 
of suffering is gone through, after a longer or shorter inter- 
val, according to the state of the patient's health and the regu- 



148 ULCEES. 

larity of his mode of life, until a decided improvement be 
produced on the constitution by time, change of climate, or 
the employment of remedies. 

The mucous membranes of scrofulous persons are apt to 
inflame, and generally pour out mucus in large quantity, 
and often of an acrid quality: not unfrequently the mucous 
membrane of the mouth presents aphthous exudations, exco- 
riations and small ulcers. 

We have already mentioned that the texture of the teeth 
of scrofulous persons is of that character which makes them 
an easy prey to caries. When we remember that teeth thus 
little capable of resistance, are continually exposed to the 
action of unusually abundant and acid mucus, we may 
readily account for the ravages of caries upon the mouth of 
persons of scrofulous taint. 

Scrofula sometimes attacks the bones of the face, especial- 
ly the nose, causing, when the disease is confined to a very 
small portion of osseous tissue, the intolerably fetid sore 
called ozena, and, when acting upon a large surface, horrible 
devastation and deformity. The bones of scrofulous subjects 
are more slender, the outer wall thinner, and their inner 
more soft and vascular than the bones of others. 

Syphilis, however, is the more common cause, both of 
ozena and osseous destruction, but it is in subjects of scro- 
fulous constitution that it produces its most fearful and irre- 
sistible effects. 

The cure of scrofula depends much upon hygienic treat- 
ment. As experience shows that cold, humid climates are 
most favorable to it, one of the best means for preventing and 
curing its disorders, is evidently removal to a warm dry cli- 
mate. Besides this, which is often impracticable, exercise in 
the open air, generous diet, and the use of such medicinal re- 
medies as are calculated to invigorate the frame, are the best 



ULCEKS. 149 

means by which to combat this obstinate and most serious af- 
fection. 

Iodine is the best medicine we possess for removing the 
superficial glandular obstructions, and healing. the ulcers of 
scrofula. It often exerts a sanitary influence upon these and 
similar external manifestations of scrofula. Unfortunately, 
the high hopes entertained at one time of the power of this 
medicine to cure the radical constitutional evil, or even the 
most fatal form of its development, tubercular phthisis, have 
been totally disappointed. This terrible form of scrofulous 
malady yields little to therapeutic agents, and, for the most 
part, is checked only by the hygienic means before referred 
to. Cod liver oil is now much used in scrofulous, and espe- 
cially phthisical cases, and seems to benefit them, either 
through some unknown medicinal principle, or, as is more 
probable, through the concentrated and highly nutritious 
aliment it affords to the wasting tissues. 

ISTo local treatment of scrofula can be depended on but the 
total destruction of the infiltrated and tuberculated tissue, 
so that a healthy basis may be provided for the new granu- 
lations. Whether and to what extent so severe an applica- 
tion of caustic shall be justifiable, must be judged by the 
surgeon in any particular case. Unfortunately, while the 
disease is local, the disorder is general. 



CHAPTER VIII. 

TUMOKS* 

The term tumor, literally means a swelling,. and is often 
used in this wide sense, but it is more properly restricted to 
such enlargements as depend upon morbid growth, either of 
the natural parts, or of matters not natural, formed in the 
tissues of the body. This definition rejects such swellings as 
are produced by the presence of free fluids and gases. 

Tumors may be divided into malignant, and those which, 
being comparatively innoxious, may, for want of a better 
term, be called benign. The former are called Heterologal, 
because they consist of structure differing from any natural 
tissue; the latter Analogous, because they are compared of na- 
tural tissue, as fat, fibrous texture and bone. 

The malignant tumors are such as depend upon some con- 
stitutional vice, and, resisting all remedies, tend to convert 
the surrounding tissues into their own substance. These 
spread rapidly, ulcerate, destroy the blood vessels of the part, 
produce frequent and exhausting hemorrhages, are sometimes 
very painful, and, if permitted to remain, ultimately fatal. 

Cancer, or carcinoma, and fungus hsematodes, or bleeding 
fungus, are the general names for these tumors, though dis- 
tinct names have been given to varieties of each of these dis- 
orders. 

We have already sufficiently noticed cancer as it affects 
the soft parts, but there is a form of it, or at least an analo- 
gous disease, which affects the bones, especially those of the 

• 
* Tumeo, I swell. 



TUMOES. 151 

face ; and of this disease, called osteosarcoma,* it is impor- 
tant that we should take some notice. 

By osteo- sarcoma, is meant a malignant disease of a bone, 
in which there takes place within it a growth of fleshy 
matter, which distends the bony walls, and gradually con- 
verts the structure into a medullary, cartilaginous, or cancer- 
ous-looking substance. 

Osteo-sarcoma announces itself by severe deep-seated pain, 
which is often felt for a considerable time before any swelling 
of the bone is perceived. Sometimes the pain is so great and 
unmitigated, as seriously to impair the patient's health, be- 
fore there is any perceptible disease. 

The tumor is at first deep-seated, general over the part, 
hard and tuberculated. It does not yield to pressure, nor is 
the pain aggravated by it.- The soft parts, for a considerable 
time, may manifest no diseased condition; indeed, it is not 
necessary to a fatal result that they should be implicated. 
Sometimes, however, as the swelling advances and the pain 
increases, the skin inflames and ulcerates, and assumes a can- 
cerous appearance. 

As the disease progresses, "hectic fever is set up, and the 
patient soon succumbs under accumulated suffering. When 
the sarcomatous bone is examined after such a termination, 
it is found transformed into a yellowish cheesy, or lardaceous 
substance, arcl all the surrounding parts which have par- 
ticipated in the disease, are found to be changed into the 
same homogeneous matter. 

The prognosis of osteo-sarcoma, is decidedly unfavorable. 
No medical treatment is of avail in checking it. Extirpation 
is the only means which promises relief. 

* 0<rnov, a bone, and cct%£, flesh. 



152 TUMOKS. 

Fungus Hoematodes, Bleeding Fungus, Spongoid Inflammation, 
Soft Cancer, Medullary Sarcoma. 

This disease is almost uniformly, perhaps always, a con- 
stitutional one, and therefore beyond the reach of any local 
means. Unfortunately we have no antidote to the poison 
shed throughout the whole body, and, therefore, there is no 
disease more intractable and hopeless. 

It generally makes its appearance in the form of a small 
elastic tumor ; at first painless, but subsequently very pain- 
ful. As it grows, its elasticity becomes more remarkable, a 
peculiarity which has originated the term spongoid inflam- 
mation. When ulceration takes place, fungus shoots for- 
ward, and the bleeding which results from these irritable and 
morbid granulations, has occasioned the name of the disease. 

Patients who suffer from fungus haematodes, have frequent- 
ly a peculiar appearance which indicates their constitutional 
pravity. Their skin is sallow, or has a greenish cast. They 
are often bedewed with clammy perspiration, and are troubled 
with cough and dyspnoea. 

Should the tumor be extirpated, the disease soon appears 
in some vital organ, and proves fatal. 

When the tumor is examined after death, it is found full 
of a grayish greasy substance, somewhat like that of the 
brain, mixed with a thin bloody matter. 

POLYPUS* 

This is the name given to a variety of tumors which have 
their seat in certain cavities, particularly the nose and uterus, 
and by their growth distend and break up the surrounding 
parts, and otherwise mechanically impede the performance 
of function, even to a fatal extent. 



* Polypus — ttokus, many — 7rovt, a foot — from a supposed resemblance to 
the radiated animal so called. 



TUMOKS. 153 

Some surgeons distinguish polypi as benign and malignant. 
Others deny that any such essential distinction exists. Pro- 
bably the disease is never malignant in the proper sense of 
that term, unless the constitutional tendency of the patient 
to some of the forms of carcinoma ingrafts the latter disease 
upon the polypoid tumor, in which case it may present the 
appearance of cancer oi fungus haematodes. 

As a general thing polypus, however dangerous, has no 
malignity about it. The harm it does is due merely to its 
bulk and unfortunate position. 

Polypus is very often seated in the nose. According to 
Mr. John Bell, every polypus, here seated, is in its early 
stage a small moveable tumor, attended with sneezing and 
watering of the eyes ; swelling in moist weather ; descending 
with the breath, but easily pressed back with the finger. It 
causes no pain, and generally begets no alarm; yet this 
small, innocent-looking tumor may become most distressing 
and fatal. As it increases, the pressure it exercises upon the 
delicate structure of the cells, &c, where it is seated, begins 
to cause serious suffering. It fills the nostrils and obstructs 
the breathing. The eyes become watery from the pressure 
upon the lachrymal sac; the hearing impaired by the ob- 
struction of the Eustachian tube, and the voice changed by the 
stoppage of the nostril. The swallowing begins to be im- 
peded by the depression of the palate; the bones become 
carious from the steady and increasing pressure ; the tumor 
projects from the nostril before and over the arch of the pa- 
late behind; the nose is twisted; the countenance distorted; 
the patient suffers with terrible headaches — a foul and fetid 
matter is discharged from the nostrils ; alarming hemorrhages 
ensue ; the floor of the antrum begins to give way ; the teeth 
fall out, and matter issues through their sockets; the still 
increasing pressure constantly aggravates the sufferings of 
the patient until death closes the scene. 
11 



154 TUMOKS. 

Though all polypi, from their tendency to grow, may in 
time produce all the terrible train of symptoms above enu- 
merated, yet we cannot agree with. Mr. Bell, that all are 
essentially similar. They differ very much in color, densi- 
ty and tendency to return. Some are pale, and so loose in 
texture as to be almost vesicular; others are red, hard, re- 
sisting, &c. But in all cases they must be removed, and it 
is of little use to distinguish between them. 

There are four ways of extirpating nasal polypi : extracting 
them with forceps ; tying them with ligatures ; cutting them 
out, and destroying them with caustic. The manner of per- 
forming these several operations is described in the books on 
general surgery. It is not within our province to recapitu- 
late them. 

Benign Tumors. — Those which have no tendency to spread 
by converting adjacent tissues, into their own substance; 
which do not depend upon constitutional vice, and may be 
considered as mere local aberrations from healthy growth. 
Of these there are several kinds, which may be reduced to 
two classes, the Sarcomatous* and Encysted Tumors and 
Exostoses. 

Sarcomatous or fleshy tumors are known by their firm, red 
and fleshy feeling. (Some of the malignant tumors are ar- 
ranged by Mr. Abernethy under this class.) There are se- 
veral varieties of them, of which the common Vascular and 
the Adipose or fatty are, by far, the most common. 

These tumors grow to great size ; are not painful, and may 
be handled with impunity. Their size and situation, how- 
ever, often make it necessary to remove them. If permitted 
to pursue their natural course, they sometimes suppurate, 
and then subside. This mode of cure, however, involves so 
much inconvenience, that it is commonly better to extirpate 
them. 

* 2 H -—fLesh. 



TUMOES. 155 

Encysted Tumors, or as they are commonly called Wens, 
have this peculiarity, that their contents are contained in a 
cyst, or sac, or bag. The contents of the cyst are various. 
Sometimes the contained matter is fatty, in which case the 
tumor is called a Steatoma* Sometimes it is a yellowish, 
thick substance, somewhat like honey or a mixture of honey 
and wax. Tumors of this kind are called Melliceris.\ When 
the contents are like fluid, cheese, or pap, the tumor is called 
Atheroma.^ 

The contents of these tumors, however, are not always of 
such a quality as will permit them to be classed under the 
names above mentioned. It is not necessary, however, to be 
more precise. Perhaps, for all practical purposes, it had 
been as well to have permitted them all to wear the popular 
designation, Wens. 

These encysted tumors are common about the head, and 
frequent upon the eyelids. They are generally globular, 
not sensitive, and cause no inconvenience beyond what is 
inseparable from their weight and size ; and the trouble from 
these causes will, of course, depend upon their location. 
They usually grow slowly, but sometimes attain great size. 
Sometimes the skin above them ulcerates, and the tumor is 
thus evacuated. This does not very frequently occur. 
These tumors should always be removed by dissecting them 
out, being careful not to leave any portion of the cyst be- 
hind ; for if this caution be neglected, the disease is liable to 
return, and does not always present, upon its second appear- 
ance, the benign character which characterized it originally. 
The operation should always be performed when the tumor 
is small, for obvious reasons. 

The mode usually adopted in the extirpation of these tu- 
mors is to dissect out the sac with the contents entire. 

* 2 T £*£ — fat. f Ui?.t, honey, and K>;§o?, wax. J A^* — pap or pulp. 



156 TUMOKS. 

Owing to the yielding nature of the contents, this is a tedious 
and troublesome process. Sir Astley Cooper recommended 
to cut through the sac at once, and then to dissect it out ; 
and doubtless this is the more easy method, inasmuch as the 
divided edges of the cyst may then be held by the forceps. 
Encysted tumors occurring in the mouth should be attended 
to as soon as they are perceived. 

Bony Tumors. — Exostosis* — An enlargement of the bone by 
the addition of osseous matter within its cavity or upon the 
surface. There are several varieties, denominated ivory, 
lamellated, &c, according to the density of the tumor, and 
the disposition of its particles. 

The bones are liable to other forms of tumefaction, which 
differ from exostosis, although often confounded with it. 
When the bones are enlarged by mere distention or sepa- 
ration of their parts, the disease is not at all similar to the 
dense tumor produced by the presence of an unnatural quan- 
tity of bony substance. 

Thickening of the periosteum sometimes occasions an ap- 
parent enlargement of the bone, when in fact the osseous 
matter is not at all increased or distended. 

Sir Astley Cooper described exostosis as having two dif- 
ferent seats, viz.: between the external surface of the bone 
and the periosteum, constituting periosteal exostosis ; and in 
the medullary membrane and cancellated structure, forming 
medullary exostosis. Sometimes he found the production of 
bone preceded by cartilage, in which it was deposited; at 
other times connected with a fungus of a malignant cha- 
racter, containing spicula. This latter form of disease seems 
to have been a variety of osteo-sarcoma. 

Exostosis may occur upon any of the bones, and the cause 
of the disease is generally inscrutable; depending upon ir- 

*E£, out of, and oa-nov, a bone. 



TUMORS. 157 

regularity of ultimate nutrition, a process which cannot be 
comprehended. 

The structure and consistence of exostosis present great 
differences. Sometimes, especially when the tumor is not 
very large, and when situated on the surface of a cylindrical 
bone, one may trace with the eye the diverging of the osseous 
fibres in the interspaces, of which we might say that there is 
deposited a new bony substance, the organization of which 
is less distinct. Sometimes the tumor is entirely cellular, 
and formed of a few broad laminae intercepting extensive 
spaces, which are filled with matter, different from the me- 
dulla, and of various quality. This case is denominated the 
lamina ted exostosis. Sometimes the enlarged portion of bone 
makes a sort of hollow sphere, with thick, hard walls, the 
cavity of which is filled with fungous granulations, more or 
less extensive and indolent. According to Boyer, this va- 
riety of the disease differs essentially from osteo-sarcoma, 
notwithstanding external appearances. The case here al- 
luded to, Mr. S. Cooper considers the same as that which 
Sir Astley has named cartilaginous exostosis of the me- 
dullary membrane.* 

In this last described form of exostosis, Sir Astley Cooper 
says that the original shell is absorbed and a new one de- 
posited, and within the ossified cavity thus produced, a very 
large mass of elastic, firm, and fibrous cartilage is formed. 
This form of disease is not malignant, but often ends in very 
extensive disease. 

A true exostosis, consisting of dense bony matter, and of 
moderate size, may exist without much inconvenience to the 
surrounding parts, provided they be of a kind to endure the 
degree of pressure without distress. But where the exostosis 
is so situated that its bulk can only be accommodated by 

* Cooper. Surg Die. 



158 TUMOKS. 

pressing upon dense and unyielding structures, or upon 
nerves or blood vessels, or where the enlargement impedes 
muscular motion, these tumors may occasion very serious con- 
sequences. The action of the flexor muscles of the leg has 
been seriously interfered with by an exostosis in the neigh- 
borhood of the knee. An exostosis of the orbit has dis- 
placed the eye. Sir Astley Cooper narrates a case of this 
kind, where two exostoses, growing from the antra, pushed 
out both eyes, and finally produced death by pressure upon 
the brain. In another instance, an exostosis of the sixth or 
seventh cervical vertebra, stopped the circulation in the ra- 
dial artery, by pressing upon the subclavian, and in another 
a cartilaginous exostosis of the medullary membrane of the 
lower jaw extended so far back, that it pressed the epiglottis 
down upon the rima glottidis, and destroyed the patient* 

The causes of exostosis are various, and, for the most 
part, little understood. The venereal disease is frequently 
attended with the formation of bony enlargements, or nodes ; 
but this cannot, by any means, be considered the ordinary, 
or indeed a frequent cause of other forms of exostosis. 

In some individuals there is an unusual tendency to 
the irregular deposit of bony matter; and provocations, 
otherwise trivial, will often determine local osseous enlarge- 
ments. Sometimes these provocations are perceived, as when 
they consist in some form of external force, as blows, pres- 
sure, &c. ; more frequently the determining cause is as ob- 
scure as the constitutional vice. 

Exostosis is always very hard, sometimes painful, often 
insensible. The firm resistance of the tumor, and its adhe- 
sion to a bone, will generally enable us. to distinguish it from 
other tumors. 

Exostosis is commonly gradual and slow in its growth; 

* Surgical Essays. 



TUMORS. 159 

but the fungous, or medullary swelling of the bones, is often 
rapid in its development. The latter form of disease is at- 
tended with very severe pain, and often with much constitu- 
tional irritation. 

Exostosis of the Teeth. 

The fangs of the teeth are more frequently the seat of ex- 
ostosis than any other part of the osseous structures. This 
affection often causes great suffering to the patient, and the 
dentist finds in it one of the most common and troublesome 
impediments to safe and easy extraction of the teeth. 

The disease is always developed upon the root ; generally 
at the extremity, sometimes upon the sides : frequently the 
whole fang is involved, though not so equally as to present 
a symmetrical enlargement. 

Mr. Thomas Bell says that the substance thus added, dif- 
fers from the natural bone, being harder, yellowish, and 
slightly transparent. As the swelling progresses, the pres- 
sure on the alveolus causes the latter to be absorbed, and 
thus, as the growth is very slow, room is continually made 
for the enlarged fang. The wasting, however, being propa- 
gated to the tooth, soon exposes the cavity to the action of 
external agents, and tooth-ache leads to extraction. Mr. Bell 
says that the continued irritation sometimes occasions thick- 
ening of the periosteum and suppuration, and the case be- 
comes one of simple alveolar abscess. 

Exostosis of the fangs sometimes occasions neuralgic suf- 
fering of a very serious grade and long duration, the cause 
of which is rarely discovered by an ordinary observer. 
Sometimes the» adjacent parts become functionally disturbed, 
and multiply the points of suffering. Mr. Fox relates the 
case of a young lady, who had suffered long with this affec- 
tion of the fangs, which her medical attendants had entirely 
overlooked. The eyelid of one eye had not been opened for 



160 TUMOES. 

two months, and the secretion of saliva was so abundant 
from the irritation that it flowed out whenever the month 
was opened. 

Professor C. A. Harris has recorded the following case:* 

Mr. S., of Baltimore, having suffered from pain in the left 
superior bicuspis, applied to a dentist in 1843, for the pur- 
pose of having this tooth removed. In the operation the 
root was fractured, about three-sixteenths of an inch from its 
extremity, and the upper part left in the socket. The pain 
continued, and at the expiration of twelve months the gum 
over the upper part of the alveolus became very much 
swollen, puffing out the upper lip to half the size of a hen's 
egg. The tumor was opened, and a large quantity of dark- 
colored, very fetid matter was discharged, which for a short 
time afforded considerable relief. The tumor, however, soon 
re-appeared, and was opened four or five times in as many 
months. 

In the fall of 1845 he called on Dr. Harris for advice. 
The gum was swollen, and the lip and cheek protruded in 
the manner above described. The tumor was opened again, 
and about three table spoonfuls of black matter, resembling 
thin tar, was evacuated. Upon farther examination, the 
outer wall of the antrum, immediately over the upper part 
of the alveolus of the bicuspis, which had been fractured; 
was destroyed, leaving an opening large enough to admit the 
end of the forefinger. Believing that the extremity of the 
root left in the socket, was the cause of the mischief, Dr. 
Harris cut away the outer wall of the alveolus, and removed 
the fragment. The root of the tooth was found exostosed. 
The patient recovered completely in a few weeks. 

A great number of cases, illustrating the variety and ex- 
tent of the mischief occasionally resulting from exostosis of 

* Dictionary of Dental Science, article Exostosis, 



TUMOKS. . 161 

the teeth., are recorded by writers upon the subject. The den- 
tist, when consulted for the relief of pain in the teeth or jaws, 
especially if of long continuance and obstinate persistence, 
should always seek carefully for evidence of bony enlarge- 
ment of the fang. It is a very common disease, and in some 
individuals affects many, or even all their teeth simulta- 
neously. Sometimes exostosis unites several teeth together. 
In a specimen presented to the Baltimore College of Dental 
Surgery, by Dr. GL R. Hawes, of New York, the three superior 
molar teeth of one side are thus united. In another speci- 
men, presented by Dr. Blandin, of Columbia, S. C, two up- 
per molars are united; and in a third, presented by Dr. 
Ware of Wilmington, K. C, there is a deposition of bone on 
the roots of a first superior molaris, as large as a hickory nut. 
Similar specimens are in the museum of the Institution. 

The disease admits of no cure, and the exostosed tooth must 
be extracted. In performing the operation, caution is ne- 
cessary lest in the effort to tear away the enlarged bulb, the 
alveolus or adjoining teeth, or a fragment of the maxillary, 
be brought with it. It is often necessary to cut away the 
socket in order to liberate the root. 

TUMOKS OCCASIONED BY ENLAKGEMENT OF BLOOD-VESSELS. 

1. Aneurismal* Tumors. 

A tumor caused by the distention of the walls of an artery 
or of the heart, is called a true aneurism ; if the swelling be 
due to the rupture of an artery and the extravasation of blood 
in the surrounding tissue, it is called a false aneurism. 

An aneurismal tumor may generally be detected by the 
throbbing or pulsating sensation which it communicates to 
the hand upon pressure. Sometimes, however, when an 

* Avsv^ewsti — to dilate. 



162 , TUMOES. 

abscess happens to be seated over an artery, the pulsation of 
the latter will be communicated to the former. The pulse 
often indicates the existence of an aneurism of the heart, or 
some large artery, by a peculiar thrilling sensation, which 
has been aptly compared to the feeling of a " shattered quill." 
As fatal accidents have occurred from thoughtlessly opening 
tumors of this description, it is always important to examine 
every tumor carefully before thrusting a lancet into it. 

The pathology and treatment of aneurism do not come 
properly within the scope of the present work. 



CHAPTEE IX. 

DISEASES OF THE TEETH AND FACE DEPENDENT UPON MOR- 
BID CONDITIONS, EITHER GENERAL OR OF OTHER PARTS. 

Neuralgia* — Certain nerves are the organs of sensation, 
and, like other parts of the body, they are liable to disease. 
When such is the case, nnless the affection be of a kind to 
lessen their sensibility, they become the seat of very severe 
suffering, which is called neuralgia. 

It may be asked whether all painful sensations are not 
seated in the nerves? we answer that they are; yet the dis- 
tinction between neuralgia and other pains, is that in the 
case of the former, the nerves are concerned primarily ra- 
ther than as instruments : or in other words, they transmit 
intelligence of their own suffering, (for such is pain) not that 
which is only shared by them with adjacent parts. We must 
not expect philosophical definitions in medicine. The term 
neuralgia is not precise, but it is sufficient for practical dis- 
tinction. 

The superficial nerves being by far the most sensitive, and 
withal, the most exposed to injury, are very much more fre- 
quently affected with neuralgia than those which are deeply 
seated. It is not certain whether the seat of the disease is in 
the neurilema, or the nervous pulp. In fact, the ultimate 
nature of the nerves is too little known to permit us to ha- 
zard an opinion upon this subject. 

* Ntv^ov, a nerve, and a\yog, pain. 



164 NEUEALGIA. 

Neuralgia is a very acute pain which generally commences 
suddenly, and occupies a single spot, from which as the at- 
tack progresses in violence, it radiates by pangs or flashes to 
the surrounding nerves. The pain is generally sharp and 
darting or burning, and may be distinguished, among other 
characteristics, by this, that in its radiations it follows the 
threads of the nerves without extending to the adjacent 
structures. There is no heat, redness, nor swelling, the ab- 
sence of which is sufficient to distinguish the disease from 
inflammation. The pain, after continuing for a longer or a 
shorter time, rarely longer than a few hours, abates, generally 
suddenly, and disappears to return with equal rapidity, if the 
proper provocation be repeated. 

The proximate cause of neuralgia is unknown, as indeed 
is its pathology. There are two varieties of it, which may 
be termed pure and intermittent. 

By pure neuralgia we mean that variety which is not, so 
far as we know, connected with or dependent upon any 
other affection, general or local. 

This disease generally occurs in pale, thin and feeble per- 
sons, and seems to be a disease of debility. The pain for 
the most part comes on suddenly, and gradually increases to 
great intensity, when either in obedience to remedies, or 
through the action of unknown laws, which regulate the ebb 
and flow of nervous influence, it abates rapidly and leaves 
the patient entirely free from suffering. It does not return 
until some provocation be applied, when it will suddenly 
re-appear, and will not be appeased for several hours. Nor 
is it necessary that any powerful irritant be applied in order 
to rouse the nerve to renewed agony. Often the slightest 
cause will be sufficient; the gentle movement or touch of the 
part, and especially the slightest breath of cool air, will often 
be sufficient to renew the terrible pain. 

The intermittent neuralgia is a symptom, and often the 



NEUKALGIA. 165 

only one of «ague, or intermittent fever ; as it is commonly 
called; but which in this case must drop the latter word, as 
there is no fever present. Of this disease we must speak at 
length presently. 

Neuralgia of each kind may be located in various nerves. 
The scope of our work makes it necessary for us to notice 
but one speciality of the disease. 

Neuralgia Faciei, or Facial Neuralgia. 

To this subject we would particularly invite our readers, 
as it is one which it is most important for all dentists to un- 
derstand. The reason will be seen in the sequel. 

Neuralgia faciei is sometimes called tic douleureux. The 
word tic means a sudden twitching or convulsive movement, 
and as this is sometimes noticed in the faces of persons suf- 
fering with neuralgia of that part, the term tic douleureux 
or painful tic, was given to the affection. 

Neuralgia faciei is seated in some of the branches of the 
fifth pair of nerves, and the first and second branches are 
more commonly its seat. The pain is therefore most fre- 
quently suffered over the orbit, in the cheek, mouth, lower 
jaw and lower teeth. 

It will be perceived at once that the dentist must often be 
called upon to discriminate between this disease and ordinary 
toothache, and that unless he be properly informed upon 
these subjects, he may add to the terrible suffering of his too 
confident patient the additional anguish of tooth extraction, 
and the injury of losing sound and most valuable organs. 

In most cases the neuralgia of the nerves of the jaw is at 
first mistaken for tooth-ache, and frequently ignorant dentists 
have extracted tooth after tooth, and have at last abandoned 
the patient to his aggravated suffering. 

The diagnosis of this malady is not difficult. From all 
acute inflammatory conditions it may be readily distinguished 



166 NEUKALGIA. 

by the absence of all the other symptoms of inflammation 
except pain ; and by the peculiar character and direction of 
the pain. The fact that it subsides, disappears and returns, 
will also serve to distinguish it from the continued pain of 
inflammation. 

From tooth-ache depending upon exposed nerves, it may 
be diagnosed by the evident centralizing of the pain in a cer- 
tain tooth, by the aggravation of it when the tooth in fault is 
struck, and by the positive evidence of a cavity in it, with an 
exquisitely sensitive pulp exposed. 

The treatment of pure neuralgia faciei is palliative and cu- 
rative. 

The palliative treatment consists in the use of such means 
as are calculated to allay the pain of the paroxysm. The 
curative consists in the employment of such remedies as ex- 
perience has shown to be most useful in restoring the health 
of the patient. Of palliative means, warmth is one of the 
most important. Cold aggravates the pain intensely, and 
will almost always excite a paroxysm of pain in a patient 
subject to neuralgia. "Warm or even hot applications to the 
face are therefore important aids in allaying the suffering. 
Counter-irritants, such as mustard plasters, blisters, cupping, 
&c, are also occasionally useful. 

But our main reliance for the relief of neuralgic pain, is in 
the use of narcotics* or anodynes, f and especially of opium, 
which is vastly superior to all the rest. 

It is necessary to give this medicine in full doses, if we 
would benefit the patient under these circumstances. An 
adult should take two grains of opium, or sixty drops of lau- 
danum, and in some severe cases, or when the patient has be- 
come accustomed to the effects of the drug, this dose will re- 
quire increase or repetition. 

* Narcotics, from ia$xo<y, T stupify. 

f Anodyne, from «, privative, and oSivrj, pain. 



NEUKALGIA. 167 

The curative treatment of pure neuralgia will be modified 
by circumstances. If the patient be plethoric with a red face 
and active pulse, even general and local bleeding may be 
premised. Such, however, is rarely the case, and when it is 
we have reason to believe that the disease is rather rheumatic 
than neuralgic. 

If the digestion be bad, which is often the case, correctives 
must be directed to the organs involved. But in most cases 
the restoration of healthy digestion will not be sufficient to 
procure permanent relief. 

Generally, neuralgia is a disease of debility, and is found 
in the cold, pale, and feeble, and in persons of evidently 
broken health. In such cases the tonic medicines offer most 
advantage, and of these none are found to be so useful as the 
salts of iron. 

There are several preparations of this medicine. The car- 
bonate, if properly prepared, is a good form for administering 
iron, but by far the most valuable preparation is the sulphate. 
This has also the advantage of being generally good as found 
in the shops, and of being always readily procured. It is 
much more certain and efficient than the .other ferruginous 
preparations. 

It may be given in doses of a grain two or three times a 
day, and must be continued for several weeks. Under its 
use the patient will generally improve in strength and color, 
and with the invigoration of the general system, the neuralgic 
affection will frequently disappear. If this medicine should 
disagree with the patient, or if it should fail after a fair trial, 
recourse may be had to other medicines of the tonic class, of 
which there are many, mineral and vegetable. 

It is a very common thing for authors and practitioners to 
confound the pure and intermittent neuralgias, through want 
of discriminating periodicity from a tendency to return upon 
slight provocation. Yet the distinction is plain and very 



168 NEUKALGIA. 

important; for upon a proper diagnosis of the form of the 
disorder depends the rational treatment of it. 

In pure neuralgia, the nerve after the subsidence of a pa- 
roxysm is left in an exceedingly irritable state, so that it will 
be excited to another by causes of irritation in themselves 
exceedingly slight. But this return is merely accidental and 
occasional, and of course, obeys no law of regular occurrence. 
In some instances the exciting cause may be so trivial as to 
escape notice, but after long and painful experience, the pa- 
tient learns to perceive potent agents for evil in things which 
previously eluded observation altogether. 

Periodicity is the regular return of paroxysms in accor- 
dance with a law of the disease and independently of provo- 
cation. It generally observes fixed periods of return and 
departure, and when irregular as to the common law which 
governs the type to which it belongs, it obeys some regula- 
tion of its own, by which some well defined proportion of pa- 
roxysm to intermission is preserved. It does not follow then, 
that because the neuralgic pain abates either of itself or un- 
der narcotics and recurs in a few hours or days, that conse- 
quently it is periodical and must be treated by quinine. 

Intermittent Neuralgia. —In order to understand the cha- 
racter and treatment of this disease, it is necessary to have a 
correct knowledge of a particular class of fevers which pre- 
sent very curious phenomena. These fevers belong to the 
class which we have designated as idiopathic ; and to the fa- 
mily of malarious or marsh fevers. They are commonly 
known as agues, from the fact that each paroxysm is preceded 
by a chill. Hence, also, they are known popularly as chills 
and fevers. 

The cause of these affections is always malaria: no other 
agent or combination of circumstances produces them, and 
this is so true that the fact of exposure to malaria is most 



NEURALGIA. 169 

important in deciding npon the character of the disease in 
mooted cases. 

Malarions neuralgia always assumes the intermittent, 
never, as far as I know, the remittent type. It may appear 
as a quotidian, tertian or quarter, or it may be irregular in 
its periods. Its paroxysms are rarely preceded by chill ac- 
companied by fever, or perceptibly finished by a sweating 
stage. Though evidently depending upon the same cause 
as intermittent fever, it has no phenomena in common with 
the former, except its paroxysmal character, periodicity and 
curability by certain specific means. 

In endeavoring to ascertain the cause of violent intermit- 
ting pains in the face, it is all-important to learn whether the 
patient has previously been exposed to malarious influence. 
If it shall appear in any instance that he has not been out of 
the central part of a large city, known to be free, at least in 
such part of it, from all emanations of a malarious kind, this 
fact is abundant evidence that the patient has not intermit- 
tent neuralgia, however strong appearances may be to the 
contrary of this opinion. On the other hand, if he lives in a 
marshy or malarious country, or if he has visited such a lo- 
cality during the latter part of the preceding summer or 
early part of the fall, and especially if the patient has had 
well marked ague previously to the facial suffering, then the 
presumption will be very strong in favor of the malarious 
origin of the disease. 

Besides this historical kind of evidence, the attending cir - 
cumstances will shed much light on the case. If there be no 
apparent cause in the condition of the teeth of the affected 
jaw for so much suffering, if no other disease can be detected 
in the bones or soft parts, if the pain intermits perfectly and 
returns periodically, or even if not with entire regularity, 
yet obviously with some obedience to the law of type, and 
12 



170 NEUEALGIA. 

without provocation, all these circumstances, taken together, 
will leave little doubt as to the nature of the malady. 

(Jure. — This distressing malady, which, if misunderstood, 
is one of the severest and most difficult to alleviate or endure, 
is when properly diagnosed a very manageable affection, and 
often yields to the very first dose of well directed medicine. 
We have previously remarked that the pathological cause 
of intermittent febrile phenomena is not known; fortu- 
nately for the world, experience has not waited for pathology, 
but has pointed out the means of relief and the mode of ap- 
plying it. 

Certain medicines are known to be positive antidotes to 
intermittent malarious fevers of all kinds. These agents if 
exhibited freely during the intermission, rarely fail to pre- 
vent the return of the paroxysm. Owing to the fact that 
most of these medicines possess tonic or roborant qualities, it 
has been supposed that they check intermittents through 
this quality. Hence, tonics are said to cure ague. 

We are convinced, however, that the supposition which 
attributes the prevention of intermittent paroxysms to the 
common roborant quality of tonics is a mistake, and a mis- 
take which probably has led to unfortunate consequences in 
practice. 

The medicines which possess in the greatest degree the 
antidotal power to intermittents, are not those which are the 
best tonics ; while the best of all roborant medicines have 
but little, if any power, to check intermittent paroxysms. 

Cinchona, or Peruvian bark, is by far the best anti-inter- 
mittent remedy we have, yet as a pure tonic it certainly is 
vastly inferior to iron, and hardly equal to some of the ve- 
getable bitters ; while arsenic, which, next to cinchona, is the 
most powerful anti-paroxysmal medicine of which we have any 
knowledge, has no tonic property analagous to that of bark. 
The anti-intermittent quality is therefore obscure, and the 
medicines under consideration are prescribed for the cure of 



NEURALGIA. 171 

these diseases ; simply because experience has clearly proved 
their preventing quality, and not because we perceive any 
rational relation between the physiological effect of the me- 
dicine and the pathological condition to be removed. 

In the treatment of intermittent neuralgia, we must rely 
upon the medicines named, or, if these fail, upon others of 
the same class. Generally, however, if cinchona and arsenic 
have failed, we must look to some other quarter than to this 
class of means for an efficient remedy. 

The best mode of administerina: cinchona, is in the form 
of the sulphate of quinine, because the dose is very much 
smaller, and sits better upon the stomach, and because, more- 
over, the cinchona in bulk is uncertain in strength. The 
best form of administering the quinine, is in solution, al- 
though pills of it are often given. 

In order to dissolve it perfectly in water, it is necessary to 
add a few drops of sulphuric acid or elix. vit. 

The dose varies very much with the circumstances of the 
case. Thus, if the intermission be long, a considerable time 
is afforded between the paroxysms, for the introduction of 
the antidote, and small doses, frequently given, are prefera- 
ble; if, however, but little intermission is afforded, the dose 
of the medicines must be proportionately greater. 

The dose, also, must vary with the urgency of the case, 
and the condition of the patient. If he has already suffered 
long, has been much reduced, and has but little power of re ■ 
sistance left, the dose should be very decided. 

There is also considerable difference of opinion among 
practitioners upon this subject. Some prefer giving large 
single doses, or at least rarely repeated ; others, small doses, 
frequently repeated. 

Generally speaking, either mode will effect the desired 
result ; but as it is plain that we should give the least quan- 
tity of medicine that will be sufficient, I am in the habit of 
prescribing moderate doses of quinine, and have never found 



172 NEUEALGIA. 

them to fail except when the stomach refused to bear them ; 
in which cases larger doses would have been yet more ob- 
jectionable. 

The prescription of quinine which I generally give, is a so- 
lution of ten grains of quinine, dissolved in an ounce of wa- 
ter. A teaspoonful, containing a grain and a quarter of qui- 
nine, being given as a dose to an adult. 

This quantity is given every two hours, if there be an in- 
termission of considerable duration, or every hour if the time 
for administering be short. 

In very serious cases of intermittent, involving great dan- 
ger to the patient, and when the powers of life were low, I 
have very much exceeded the quantity above named. Some 
practitioners always give it in doses of ten or twenty grains, 
but this quantity is unnecessary and hardly safe ; for though 
many patients would bear it without inconvenience, some 
would suffer from its action upon the brain. 

The dose of quinine to young children must always be 
very small, as their nervous system is more excitable, and 
their brain more easily disturbed than is the case with 
adults. 

Next to quinine, arsenic is our most certain antidote to 
intermittent affections. It is given in the form of the arse- 
nias potassae, or Fowler's mineral solution, in which form it is 
manageable, and in proper doses entirely safe. The viru- 
lently poisonous character of arsenic, renders it improper to 
attempt its administration in any but a diluted form. 

There are many cases in which the arsenic appears to ex- 
ercise the anti-intermittent power quite as efficiently as cin- 
chona, and the small bulk of the dose, and the readiness with 
which its flavor may be covered, make- it far preferable for 
administration to children. 

It may be given very advantageously in alternate doses 
with quinine. After it has been persevered in for a long 
time it is apt to produce cedema, which readily subsides 






NEURALGIA. 173 

when the medicine is withdrawn. The dose of Fowler's so- 
lution, to an adult, is from six to ten drops, every one, two, or 
three hours, or alternating every four hours with quinine. 
Sometimes it produces nausea and irritation of the bowels. 
In such cases the dose should be lessened. 

There are many other remedies which are more or less ef- 
ficacious in the prevention of intermittent paroxysms, but it 
is not necessary to mention them here. 

The quinine and arsenic should be given only during 
the intermission; though, if this be very short, the adminis- 
tration of remedies, and especially of the arsenic, may be re- 
commenced before the fever has entirely subsided. 

In the treatment of intermittent neuralgias, as in other in- 
termittent affections, the prevention of a paroxysm will be 
more certain, if a full dose of opium be given an hour before 
the expected return. 

In cases of intermittent neuralgia, where the patient has 
been exposed to malaria for successive years, and has suffered 
much from the diseases attributed to this cause, the liver 
and abdominal viscera are generally deranged, and the neu- 
ralgia cannot be permanently relieved until these visceral 
obstructions are overcome. 

The purgative preparations of mercury are very useful 
in such cases. 

Of course, no permanent cure can be expected, while the 
patient shall continue to reside in the unhealthy location, as 
he must, of necessity, be exposed to continual renewal of the 
disease. Unfortunately, the advice of medical men is rarely 
of much avail in directing the choice of residence. This is 
determined, for the most part, by considerations entirely in- 
dependent of health; and there is great difficulty in per- 
suading a man that it is unsafe for him to live where it is 
most profitable or pleasant, and that his own property is si- 
tuated where nobody ought to live. 



CHAPTBE X. 

MOEBID SECRETIONS OF THE MOUTH. 

Six glands, the parotid, submaxillary, and sublingual of 
each side, pour their secretions into the cavity of the mouth. 
The mucous membrane, which lines the organ, also contains 
upon its surface a great number of crypts, or follicles, which 
prepare and pour mucus into the mouth. The secretions 
from the glands and mucous membrane, form saliva, which 
lubricates the facial cavity, and in mastication is thoroughly 
mixed with the food, the subsequent digestion of which it 
materially aids. 

The mucous membrane of the mouth is continuous with 
that which lines the pharynx, oesophagus, stomach, and in- 
testines, and sympathizes greatly with any diseased condi- 
tion which affects those organs. Hence the furred tongue 
in fever, the red tongue of intestinal irritation, &o. 

The fluids of the mouth are readily changed from their 
normal condition, when the digestive organs are feeble and 
perform their functions badly. When such is the case, the 
secretion of the stomach and its appendages are so changed 
as to unfit them for the perfect performance of their work: 
they become, to a certain extent, foreign matters, and are 
capable of exciting irritation, and also, by mixing with ali- 
mentary matters, of converting them into deleterious agents. 
Generally the change produced upon the fluids of the sto- 
mach, &c, under such circumstances, renders them, more 
acid. 

Corresponding changes often take place in the fluids of 



MORBID SECRETIONS OF THE MOUTH. 175 

the mouth. They also become acid, and in such cases cor- 
rode the dental structures, and cause great devastation of 
the teeth. 

They are also liable to be produced in excess, and to be 
very abundant in salts, which are collected, mixed with vis- 
cid mucus, about the teeth, especially of the lower jaw, form- 
ing the several varieties of tartar. 

The saliva of healthy persons is only sufficient for com- 
fortable lubrication of the mouth, and being passed into the 
stomach as fast as it forms, it does not collect in the mouth, 
or require to be frequently excreted. When healthy, it is 
light, frothy, and but little viscid, without odor, and floats 
upon, and mingles readily with water. In this condition it is 
slightly alkaline. 

The saliva is acid in dyspepsia, and consequently caries is 
apt to prey upon the teeth of persons suffering with indi- 
gestion. Nor may the dentist expect to arrest the devasta- 
tion, unless he can remove the cause that is continually de- 
composing the bony structures of the teeth. 

That the saliva is acid in certain diseases, is abundantly 
shown by M. Donne, of Paris, — who was so struck with 
the changes in the chemical character of the fluids of the 
mouth, as responding to disordered states of the stomach, 
that he suggested the use of this fact, as the best means of 
deciding upon doubtful cases of such disorders. 

MM. Tiedemann and Grmelin had previously found the 
saliva to be alkaline in man, and all other animals whose se- 
cretions they had examined. Magendie, with his usual care- 
lessness of facts, and. boldness of theory, taught that the sa- 
liva was sometimes strongly alkaline, sometimes neutral, and 
sometimes acid: when the stomach is empty, the fluids of 
the mouth, according to this writer, are acid; during masti- 
cation, alkaline ; the acidity disappearing sometimes at the 



176 MORBID SECRETIONS OF THE MOUTH. 

presence of the first mouthful. The latter part of this opi- 
nion is, of course, mere nonsense. 

According to M. Donne, who seems to have investigated 
this matter with great carefulness, with the hope to find in 
it some semeiological fact, which might lead to great practi- 
cal results, the saliva is constantly alkaline when the stomach 
is in a healthy condition. This, then, he considers the nor- 
mal or natural quality of the fluids of the mouth, and all de- 
viations from it he considers unhealthy, and indicative of 
gastric disease. M. Donne declares that he has never found 
the saliva acid, when the stomach has performed its func- 
tions well. 

The only testing means used by this gentleman in his 
many experiments upon the saliva, were slips of litmus pa- 
per. The saliva, if acid, will redden the paper : for test of 
alkalescence the paper should first be reddened by an acid 
and then subjected to the action of the saliva. 

M. Donne narrates a number of cases of various forms of 
disease, in all of which the stomach was deranged and the 
saliva acid. We. will quote a few of them. 

A young woman was admitted into the hospital of La 
Charite, laboring under severe bronchitis, attended with 
great tenderness of the abdomen, excessive irritability of the 
stomach, diarrhoea, ardent thirst, &o. The saliva was 
strongly acid. The disease assumed in its progress a marked 
typhoid character, the tongue was parched and coated with 
a brown crust, the abdomen was always very tender; deli- 
rium and coma supervened, and the patient died on the tenth 
day after admission. The saliva was acid during the whole 
course of the illness. Dissection showed extensive disease 
of the mucous membrane of the stomach and intestines. 

A young man was received into La Charite, as a fever pa- 
tient. All the symptoms of ataxic* fever soon developed 
themselves. The saliva during the first days was only 
* Literally, — disorderly, — a name given to typhoid fever. 



MOEBID SECKETIONS OF THE MOUTH. 177 

slightly acid, but later it became more strongly so ; he died 
comatose. The saliva remained acid to the end. Dissection 
showed a fifth part of the mucous membrane of the stomach 
diseased. 

A young man was admitted into the hospital as a fever 
patient. The symptoms were not serious ; there was a yellow 
hue of the skin ; the epigastrium was rather tender on pres- 
sure; there were, however, neither vomiting nor diarrhoea 
present ; the tongue was white, and the saliva was alkaline. 
During the progress of the case the saliva became acid, con- 
tinued to be so for three days, then became neutral, and as 
the patient recovered, gradually resumed its alkalinity. 

In the case of a young man who exhibited the symptoms 
of gastritis, namely, great tenderness of the epigastrium, 
thirst, tongue red and parched, &c, the saliva was found to 
be decidedly acid. By repeated leechings of the abdomen, 
and the use of demulcent and refrigerant drinks, the symp- 
toms were speedily relieved, and in a few days the saliva 
was quite neutral, having no effect either on the simple lit- 
mus paper, or on that which had been previously reddened 
by an acid. It soon regained its alkalinity. 

This patient had two relapses of his complaint, and on 
both occasions the saliva was acid at first, and became neu- 
tral, and then alkaline, as the symptoms disappeared. 

From these and similar facts, M. Donne inferred that aci- 
dity of the saliva was always attendant upon gastric disorders 
of a febrile character. 

Professor Harris informed me that repeated experiments 
satisfied him that the acidity is confined to the mucous 
secretions of the mouth; the secretions from the salivary 
glands never reddening the litmus held to the mouth of their 
ducts. 

Schill observes that " carious teeth indicate long continued 
irregularities of digestion. The teeth become very sensible 



178 MOKBID SECEETIONS OF THE MOUTH. 

(sensitive) in many nervous diseases, and in consequence of 
the presence of acid in the stomach. They are sometimes 
covered with a whitish or gray mucus ; this occurs chiefly 
in catarrhs, and inflammations of the digestive and respira- 
tory organs."* 

When we remember the extreme susceptibility of the teeth 
to be decomposed by the action of acids, (see page 41,) we 
may well understand why caries is so general, and so hard 
to arrest. Providence has made the saliva alkaline, in order 
to protect the important organs it bathes from injury by 
acid matters taken into the mouth, and also to moderate the 
acidity of the gastric fluids. 

But under many morbid conditions, especially those most 
common to artificial life, the protecting fluid itself becomes 
the assailant, and the teeth exposed at once to the attacks of 
acid aliments and drinks, and to the more constant action 
of acidulent saliva, soon yield to those corrosive agents. 

This acid state of the saliva may accompany a vitiated 
condition of the fluids of the stomach, when no gastric suf- 
fering has attracted the attention of the patient, and the ex- 
istence of any disorder in that organ has not been suspected. 
In such a condition of things, however, the dentist can afford 
only temporary relief, unless, perceiving the evil himself, he 
suggests such remedies as may relieve the patient of it. 

The practitioner of dentistry should, therefore, be always 
prepared to test the quality of a patient's saliva as regards 
acidity or "alkalescence; and he should also be prepared to 
give such advice as may be necessary, in consequence of 
any discoveries he may make. 

When diseases of an acute character exist there will be 
no demand for the services of the Dental Surgeon, unless his 
mechanical assistance be required. It is not necessary, 

* Schill's Semeiology. 



MOEBID SECBETIOXS OF THE MOUTH. 179 

therefore, for us to treat of such affections. But it often 
will happen, that a patient will apply for operations upon 
the mouth, who may be affected with some sub acute or 
chronic disease of his stomach, for which he is not under 
medical treatment. If the disorder be not very trifling, the 
dentist ought, in such cases, always to advise application to 
a judicious physician. But it will often happen, that the 
patient cannot conveniently procure such attention, or that 
the dentist may not have such confidence in the skill of the 
medical practitioner who could be procured, as to authorize 
him, as a conscientious man, to devolve the case upon another. 
He must therefore give the necessary advice himself. 

In calling the attention of the dental student to the consi- 
deration of dyspepsia,* as a common name for chronic dis- 
eases of the stomach particularly characterized by indiges- 
tion, we do not think we are in any degree leading our read- 
ers away from the studies proper to them. 

Dyspepsia or indigestion, representing any derangement 
of the function by which the aliment after having been re- 
ceived into the stomach, is converted into chyle, must neces- 
sarily present a number of appearances, more or less cha- 
racteristic of the particular trouble they represent, and the 
degree of its violence. It is therefore impossible to furnish 
a description sufficiently accurate and comprehensive to 
cover all the conditions of defective digestion which are in- 
cluded under the common name dyspepsia. Several com- 
plicated organs are concerned in the process of digestion. 
These are connected together by the natural dependence of 
reciprocal necessity, and by powerful sympathies ; and any 
of them when diseased may interrupt the functions of the 
others. To understand this subject well, it will therefore be 
necessary to have a complete knowledge of all the morbid 

* Dyspepsia — At/?, 'with difficulty,' and Ubtitoiv, — 'to digest.' 



180 MOEBID SECKETIOKS OF THE MOUTH. 

conditions of all the organs of digestion, and of all the means 
likely under any circumstances, to be useful in restoring 
them to healthy action. 

Of course, it is not our purpose to discuss this subject in 
all its fulness of detail. Itwill be sufficient to impart such 
practical information; as may be easily remembered, and 
readily made available by the dental practitioner. 

The symptoms of dyspepsia vary much with the duration 
and nature of the affection, the constitution of the patient, 
his mode of life, &c. 

Generally the appetite is capricious, sometimes very feeble. 
Heartburn, a sense of weight or distention in the stomach 
after eating, incapacity of digesting certain substances, such 
as oily matters, pastry, &c, costiveness, abdominal pains, 
weakness, depression of spirits, &c, are most prominent. 

From the extensive sympathies existing between the sto- 
mach and brain, headache is a very common attendant upon 
dyspepsia. This is often very violent, and attended by nau- 
sea and vomiting. The patient soon learns by experience 
that he cannot take certain articles of food or drink with im- 
punity, and every deviation from the diet suitable for him, 
is attended by renewal of symptoms, and aggravated suffer- 
ing. 

Dyspepsia may be variously classified for the purpose of 
description and treatment, but the simple, plain, and practi- 
cal distinction laid down by Dr. Eberle seems preferable for 
our purpose to any of the more accurate, yet more compli- 
cated arrangements presented by other writers upon this 
subject. According to Dr. Eberle, dyspepsia may depend 
upon two distinct morbid conditions of the digestive organs, 
viz; 1. On functional debility of the stomach from deficient 
or vitiated secretion of the gastric fluid, and muscular inac- 
tivity, independent of vascular irritation or inflammation. 
2dly. On deficient or vitiated secretion of the gastric fluid 



MOEBID SECRETIONS OF THE MOUTH. 181 

with vascular irritation or chronic inflammation of the mu- 
cous membrane of the stomach and duodenum, and a mor- 
bidly increased peristaltic action of these organs. 

The characteristic symptoms of the former grade of indi- 
gestion, are weak appetite; tongue covered with white fur; 
absence of epigastric tenderness, except after a paroxysm of 
colic from flatulent distention; costiveness; acid and fetid 
eructations; absence of habitual tension and febrile irrita- 
tions of the pulse ; and the ability of bearing lean and tender 
animal food better than vegetable and farinaceous articles of 
diet. 

The phenomena which characterize the second or inflam- 
matory grade of the disease, are tenderness to pressure of 
the epigastrium, and particularly about the region of the py- 
lorus and duodenum; a red, chopped, granulated or glossy 
appearance of the tongue ; a firm, tense, small and somewhat 
accelerated pulse, with slight manifestations of febrile exa- 
cerbations towards evening; emaciation; irregular action of 
the bowels, with frequent attacks of mucous, bilious, or wa- 
tery diarrhoea; violent protracted pain in the lower part of 
the epigastrium during the process of digestion; fulness 
about the edge of the false ribs on the right side ; an anxious 
and discontented expression of the countenance; and inabi- 
lity, without great suffering, to endure animal food and sti- 
mulants. It appears that the irritative or chronic inflamma- 
tion of such cases is seated in the mucous membrane of the 
pyloric extremity of the stomach, and of the duodenum, 
connected usually with a congested state of the liver and of- 
ten with foecal accumulations in the colon.* 

The causes of dyspepsia are : 

1st. Hereditary predisposition. Some families inherit from 
their parents some peculiarities in the intimate organization 

* Eberle's Prac. of Mediciae. 



182 MOEBID SECKETIONS OF THE MOUTH. 

of the stomach which inevitably result in dyspepsia of pro- 
tracted and aggravated character, which makes its appearance 
about or soon after puberty, and continues with more or less 
intermission for years. This predisposition, however, is not 
of very frequent occurrence. 

2d. Mental and moral causes, such as exaggerated passions; 
gloomy habits of thought; depression of spirits; over anx- 
iety of mind. 

The influence of the feelings over the stomach is well 
known. Grief destroys the appetite, so do joy and ardent 
anticipation. Fasting is a natural exponent of sorrow. 

3d. Irregular living, especially the artificial life of the fa- 
shionable world, which turns night into day and day into 
night ; robbing the body of sleep when most disposed to and 
best prepared for it, and forcing the stomach, at unnatural 
hours, to eat heartily of the most indigestible and irritating 
kinds of food, if such ingesta can thus be called without im- 
propriety. 

4th. Luxurious and excessive eating and drinking, both of 
water and intoxicating drinks. 

5th. Sedentary living without sufficient exercise. 

6th. Unwholesome and insufficient diet. The use of 
pickles in excess, especially by delicate females. 

7th. Want of healthful and sufficiently laborious occupa- 
tion. It is owing to this, together with the adjuvant action 
of other causes which we have mentioned, that so many of 
the young women of our country are feeble, diseased, useless, 
and short-lived. 

8th. The abuse of medicines, especially those of a purga- 
tive character. People have a wonderful disposition to be 
actively purged. Millions of pills, containing irritating and 
powerful cathartics, such as jalap, scammony, aloes, calomel, 
gamboge and croton oil, are annually sold to persons whose 



MOEBID SECKETIONS OF THE MOUTH. 183 

only disease is too frequent purgation. The result often is 
chronic and incurable dyspepsia. 

9th. Eating too fast, so that the gastric juice does not min- 
gle with the food as rapidly as it is taken. Imperfect mas- 
tication, generally, because of carious teeth. 

10th. Extensive disease of the teeth, occasioning frequent 
and severe tooth-ache, vitiating the secretions of the mouth 
and thus furnishing to the stomach saliva of a bad quality. 
We have just seen that imperfect mastication may cause dys- 
pepsia. Extensive caries interferes much with mastication. 
Moreover, pain disturbs digestion, and frequent tooth-ache 
not only produces the common effects of pain, but from the 
position of the suffering, interferes with insalivation and re- 
gular eating 

11th. To all these causes may be added everything which 
tends to exhaust the vital energies, as every kind of excess 
necessarily does. 

The treatment of dyspepsia consists first, in removing as 
far as possible all the causes of it. It will be useless to make 
an attempt to cure, unless the patient will make patient and 
self-denying efforts. 

The patient must be contented to subsist upon such food as 
he can readily digest. The diet should be as dry as possi- 
ble, for all drinks dilute the gastric juice, and when this is 
vitiated or deficient, dilution renders it still less efficient. 

As to the character of food, it is exceedingly difficult to 
lay down a bill of fare which will suit all cases. The sto- 
mach, in dyspepsia, is very capricious. Some patients will 
eat with impunity what others cannot digest at all. I once 
had a dyspeptic female patient whose stomach revolted at 
the most simple and digestible substances, yet retained and 
digested comfortably, apple pie and milk. Grenerally, the 
patient has learned, by repeated experiments, what food 
agrees best with him, and to this he should be confined. 



184 MORBID SECRETIONS OF THE MOUTH. 

In general, when the disease is simply one of debility 
without gastric inflammation, animal food answers better 
than vegetable. In selecting the particular kinds of animal 
food, we should avoid young meats. Yeal, lamb, and young 
pork are very indigestible by weak stomachs. The mode of 
preparation also is important. Soups of all kinds are perni- 
cious, as they present the food to the stomach very much di- 
luted and mixed with oily matters. Oils in all forms must 
be avoided, hence fried food, melted butter, gravies, most 
kinds of fish, &c, are inadmissible. All acid fruits, and the 
whole family of nuts, come under similar condemnation. 
Sugar is very apt to sour upon the stomach, especially if it 
be dissolved in warm water, as in the form of sweetened tea 
and coffee. 

In these cases of debility of the stomach, a little brandy 
taken at dinner is often very serviceable. The remedy, 
however, is a dangerous one, and no prospect of advantage 
from it should induce us to advise it to one who has at some 
previous time been intemperate in its use. It is better for a 
man to be a dyspeptic than a sot ; and reformed inebriates 
have seldom a choice between abstinence and excess. In- 
deed every patient who may be advised by his physician to 
use ardent spirits, should be faithfully warned against the 
danger of acquiring an intemperate love of alcoholic excite- 
ment. 

The medicinal treatment of such cases consists in the em- 
ployment of such occasional purgatives as may be necessary 
to procure regular alvine evacuations; in the proper use of 
mild mercurial means to an extent sufficient to remove tor- 
por of the liver; in the administration of alkalies, if the pa- 
tient be troubled with an excess of acid ; and finally, in the 
use of suitable tonics. All purgative medicines are not by 
any means equally well suited for the purpose we have indi- 
cated. Those of them which are very harsh and irritating, 



MOEBID SECKETIONS OF THE MOUTH. 185 

and those which produce watery arid exhausting discharges 
would be very injurious to dyspeptics. Indeed, we have 
enumerated the abuse of these cathartics among the common 
causes of the disease. • 

Bhubarb, from its aromatic and tonic quality, and its mild- 
ness, is one of the best medicines for habitual use, under 
these circumstances. Aloes is somewhat stimulating to the 
torpid intestine, and generally acts very gently upon the 
lower bowels. Blue pill mixed with either of the medicines 
above named will often prove very advantageous, and calomel 
given occasionally in a decided dose will be very serviceable 
when the liver is indolent, and its secretions deficient either 
in quantity or quality. 

Of the vegetable tonics, the pure bitters, such as quassia 
and gentian are the best. But the preparations of iron are 
more likely to be decidedly advantageous. 

We must not, however, expect a great deal from medicine 
in the relief of dyspepsia. At most it is a secondary means 
of cure. The removal of the causes and the rigid adherence 
to regimen, will, in most cases, ultimately procure relief. 

It is very important that the teeth of dyspeptic persons be 
carefully examined ; for often the cause, or at least a cause of 
the disease may be found in the diseased and defective con- 
dition of these organs, and a speedy cure be obtained by 
their removal. 

As to the form of dyspepsia attended by sub-inflammatory 
condition of the lining membrane of the stomach, its cure 
must be devised upon the principles which govern in the 
treatment of similar conditions elsewhere. Moderate anti- 
phlogistic means and mild farinaceous diet, will general- 
ly be attended with permanent relief; nevertheless, the gas- 
tric surfaces, as the mucous membranes elsewhere, after 
having been inflamed, remain subsequently very susceptible 
13 



186 MOEBID SECKETIONS OF THE MOUTH. 

to renewal of the disease, and the patient when relieved must 
be very careful not to presume upon the comfortable feeling 
of his stomach, and introduce into it stimulating meats, con- 
diments or liquors. 

All dyspeptic persons should be advised to eat slowly and 
chew their food well. If the absence or bad condition of 
the teeth interfere with mastication, as will often be found 
to be the case, the skill of the dentist must supply the defi- 
ciency or repair the injury of these important organs. 

Dyspepsia or indigestion expresses only the mal-perform- 
ance of an act which is the result of the combined effects of 
various organs. Therefore, as failure of function in any one 
will interrupt the healthy completion of the great common 
purpose, dyspepsia must be a general term comprising 
several disorders. Being immediately connected with the 
digesting apparatus, and in fact forming an important part 
of that great and complicated system by which aliment is 
received and prepared for assimilation, the dental apparatus 
can hardly escape injury when the other organs of this sys- 
tem are involved in suffering. Indeed, the mucous membrane, 
which in the stomach and intestine is the seat of the digesting 
process, and in the mouth is continually pouring out im- 
portant fluids from its surface and glands, is so intimately 
connected with the dental arch as to unite it in close sympa- 
thy with the more important organs of alimentation. A 
healthy state of the fluids of the mouth is necessary for the 
safety of the teeth, and the secretions of the mouth will not 
be healthy when the functions of the intestinal canal are 
disturbed. It is a hopeless task to save the teeth from 
caries while the patient suffers unmitigated dyspepsia. 

Syphilis, also, by vitiating the general glandular and se- 
creting systems, may produce a state of the buccal fluids 
very inimical to the structure of the teeth. This will only 
he the case in those secondary or constitutional forms of lues 



MOEBID SECKETI0N3 OF THE MOUTH. 187 

of which we have already written sufficiently when treating 
of ulcers. 

Eickets very much delays dentition, and so impairs the 
structure of the teeth that when protruded they are very lia- 
ble to decay. 

The enamel of teeth formed under the influence of this 
constitutional vice, is often craggy and worm-eaten in ap- 
pearance, though sufficiently hard. The fang, during the 
progress of the disease, has been found somewhat softer than 
natural. 

The exanthematous febrile affections, which commonly 
occur in childhood, interrupt the regular deposit of bony 
matter in the growing teeth, and cause permanent defects, 
which are sometimes discernible in the external appearance 
of the organs. 

Measles, for instance, often leaves evidences of its visit 
upon the enamel of the teeth, in the pitted appearance which 
they present. 

As fever of all kinds is always attended with vitiation of 
the secretions of the mouth, we may readily perceive how 
any protracted disease of this kind may injure the teeth. 

All serious diseases of the antrum must involve the dental 
arch. Inflammation may be propagated, nutrition impeded; 
caries communicated, and the arch actually broken up in the 
course of those often fatal diseases which have their seat in, 
this geographically important cavity. 

The surgeon dentist should be well acquainted with the 
various disorders and morbid growths which may be deve- 
loped in the antrum. Early detection is often necessary to 
cure, and none is so likely to have the opportunity of early 
discovering the hidden mischief, as the dentist. The first 
symptoms of the disorder are often felt in the teeth, and un- 
less the dentist who may be consulted shall be able to point. 



188 MORBID SECRETIONS OF THE MOUTH. 

out the true nature of the evil, delay may be occasioned, and 
delay may be fatal. 

Mercurial salivation, (ptyalism) has often caused extensive 
devastation in the dental arch. Mercury, like all other of 
Heaven's boons, has been shamefully abused, and serious and 
even fatal injuries have resulted from the reckless adminis- 
tration of this most useful medicine. Unhappily, the oc- 
currence of such calamitous accidents, has induced such ge- 
neral and unreasonable prejudice against the use of mercu- 
rial medicines, that vastly more evil is now suffered by so- 
ciety from the improperly withholding, than injudiciously 
using them. The feeling against mercury has been the com- 
mon hobby-horse of charlatans and unprincipled physi- 
cians, and it needs no little firmness to enable one to deal 
honestly with his patient in the use of this drug. From the 
fact that salivation is injurious to the teeth, dentists have 
been led to comment severely on the use of calomel, and thus 
have done much to spread abroad terrible notions of the evils 
inseparable from the employment of this and other mercu- 
rial preparations. Some of these censorious gentlemen have 
seen evidences of mercurial devastation in every form of dis- 
order and variety of decay ; and to them, calomel is the one 
thing to be avoided by all who live to eat, or eat to live. 

Doubtless salivation, especially if profuse, must be destruc- 
tive to the teeth : fortunately it is at length understood that 
ptyalism is not by any means necessary to the attainment of 
all the benefit of mercury. Salivation is an accident always 
to be dreaded, and as far as possible to be avoided. Yet, even 
at the risk of it, mercurial remedies are indispensable, inas- 
much as life is more important than teeth. 

There is no reason to believe that the use of mercury is in- 
jurious to the teeth, when salivation is not induced; yet ca- 
ries of these organs is very often attributed to it. People 
are exceedingly apt to confound the post hoc with the prop- 



MOKBID SECRETIONS OF THE MOUTH. 189 

ter hoc,- and dentists are as liable as other men to fall into 
the error. A patient who has escaped a severe attack of 
fever, finds his teeth rapidly decaying; in great alarm he 
applies to the dentist. The latter glances at the month and 
with a look of boding sagacity, inquires if the patient has 
not been taking calomel. The patient replies that he has 
been taking more or less, and then the man of science, as he 
is presumed to be, launches forth for the hundredth time 
into a bitter diatribe against mercury as the origin of all 
evil. 

And why might not the lamented caries be as justly 
charged upon the tartar emetic or magnesia, which the pa- 
tient may have taken simultaneously with the calomel ? or 
why does not the dentist seek for the all-sufficient cause of 
devastation in the fact that the teeth in question had been 
bathed in the acid saliva of a fevered mouth for weeks con- 
secutively ? Why transfer the blame to the remedy by which 
the fever was subdued, and cast implied and serious censure 
upon the physician, whose judicious employment of the vi- 
lified drug has, perhaps, saved the patient's life ? 

Until we have other information than we now possess, we 
cannot believe that the proper employment of mercury is 
injurious, and while we reprobate its abuse and would think 
the physician unpardonable, who would be careless or reck- 
less in the use of a medicine capable of doing so much harm, 
we cannot but regard that man as the author of greater 
evil, who by silly declamation against an important remedy, 
fetters the physician in his contest with the most formidable 



Scrofula, to which we have already called attention, inter- 
feres with assimilation, and consequently with the com- 
pleteness of nutrition and growth. Being often inherited, and 

* To consider whatever occurs subsequently, to be consequent upon what 
has been observed to precede it. 



190 MORBID SECRETIONS OF THE MOUTH. 

developing its mischievous nature very early in life, it in- 
fluences the teeth during the important process of formation, 
and by preventing their perfect organization renders them 
feeble to resist the influence of morbific causes. 

This evil consequence is, however, generally counter- 
balanced by the thinness and deficiency of mucous and sali- 
vary fluid, and the difficulty with which the fluids of the 
mouth of strumous persons become acid. 

Pregnancy is supposed to be fraught with danger to the 
teeth. Indeed, this opinion has been sufficiently general to 
have become condensed in the adage — "for every child a 
tooth " — meaning that the mother may expect to lose a tooth 
as the result of each pregnancy. 

Pregnancy is not disease, it is a physiological condition, 
and we cannot believe that it is per se, and naturally, a cause 
of disease anywhere, especially in organs distant and not im- 
mediately dependent upon the uterus. But in pregnancy 
the nervous system is irritable, and the sympathies of the 
body are in more lively play. The vascular action is also 
greater and the blood is more highly charged with flbrine. 
It therefore happens that there is more liability to pain then 
than at other times, and less patience to endure it. Conse- 
quently, if the woman has any diseased teeth, previously neg- 
lected, they will be apt to ache, and when aching, the pain 
to her irritable nerves is intolerable. Besides this, there is 
occasionally a sympathetic tooth-ache, which, though it can- 
not be directly traced to the uterus, certainly depends upon 
its gravid condition, and not upon disease of the tooth itself. 
The dentist should be aware of this ; it is readily alleviated 
by an anodyne. 

It also happens very frequently that the artificial life and 
the absurd habits of our young females, induce a constitu- 
tion but little capable of sustaining child-bearing, although 
to the woman of good health and vigorous frame, parturition 



MORBID SECRETIONS OF THE MOUTH. 191 

is fraught with no disadvantage to health or shortening of 
life. These pallid, soft, and delicate girls, when they become 
pregnant, begin rapidly to break down, and the rapid caries 
which destroys their teeth is but the first manifestation of 
the premature decay of the whole body. This is a subject 
upon which we could and would willingly write much, but 
it would be useless. 

Fashion, custom, inclination will bear sway over reason 
and moral obligation, — years of comfort will be sacrificed for 
hours of mirth, — showy dress and ball room vigils will con- 
tinue to feed the insatiable tomb with the loveliest of our 
race. 



CHAPTEE XI. 

MORBID EFFECTS OF CONDITIONS OF THE TEETH, AND THE 
PARTS IMMEDIATELY CONNECTED WITH THEM, UPON THE 
GENERAL SYSTEM. 

Having considered the several forms of disease in other 
parts, or of the general system, which morbidly affect the 
teeth, we proceed to inquire what effect these latter organs, 
in their varied states, whether physiological or pathological, 
may induce in other parts, and what changes they may cause 
in the more general phenomena of vital action. 

As the body is a unit, knit by the closest bonds, pervaded 
by one system of blood-vessels and nerves, directed by one 
intelligence, and kept in a continual relation of function 
and expression by an all-pervading law of reciprocal re-ac- 
tion and sympathy; as diseases of other parts, and those 
which in distinction to well denned and limited affections we 
call general, are capable of affecting the teeth, it might be 
apparent, if we had no particular facts in evidence, that the 
morbid condition of the teeth may produce corresponding 
evils in other parts, and may even involve the whole system 
in troubled and morbid action. 

It might also be evident that severe and long- continued 
pain, located in the immediate vicinity of the brain, and in 
parts little accessible to soothing appliances, cannot be less 
dangerous to health than pain in other organs situated at 
greater distance from the nervous centres, and more easy of 
access. 



MOKBID EFFECTS OF THE TEETH, ETC. 193 

It might also be perceived that sensitive organs, in imme- 
diate contact with the great lining membrane of the thoracic 
and abdominal cavities, and intimately connected with it by 
function, cannot be less capable of propagating disorder to it 
than parts located far from it, and having no immediate re- 
lation to it. 

Yet natural as these inferences may seem to be, they have 
been, until lately, almost entirely overlooked, and even now the 
medical profession are by no means awake to the facts, and 
the importance of the morbid relation actually existing be- 
tween the teeth and other parts. 

It is exceedingly uncommon to hear that a physician, in 
searching for obscure causes of protracted ill health, has 
paid attention to the state of the teeth, though often their ter- 
ribly diseased condition cannot escape involuntary recogni- 
tion by more of his senses than one. The matter is never 
alluded to in lectures delivered to medical classes, and, in 
fact, is hardly recognised at all as a subject for pathological 
or hygienic consideration. 

Within a few years, however, several writers upon den- 
tistry have urged the medical profession to turn their atten- 
tion to the diseased conditions of the teeth in connexion with 
other disorders, and they have supported their appeals with 
such an array of well observed and clearly narrated cases as 
must impress the mind of all reflecting readers with the fact 
of the morbid relations in question. 

Unfortunately, these writings are not read by the general 
practitioner, and it is to be feared that a long time must 
elapse before physicians become properly informed upon this 
subject. In the meantime it is the more important that every 
dentist be able to perceive these sympathetic conditions and 
call the attention of the patient and physician to them. 

The teeth, while in a physiological condition, are capable 
of inducing great local distress, and constitutional disorder 



194 MOEBID EFFECTS OF THE TEETH, ETC. 

even of a fatal kind. During their evolution and passage 
through the gum, the pressure even of a sound tooth upon a 
sound gum may be attended by irregular phenomena of the 
most alarming kind: it would be strange, indeed, if the ac- 
tion of a diseased tooth upon the diseased gum should be at- 
tended with no evil consequences. 

That the process of dentition happens in infancy, causes 
certainly a modification of effect in accordance with the pe- 
culiarities of the infantile constitution; but the action of 
morbid teeth upon the less mobile nerves of the adult may 
be as certain, though less rapid and ostentatious. 

The question, however, like other medical questions, is 
one of fact, not of inference. And we would leave the truth 
to be deduced from a fair examination of subjected cases. 



CHAPTEE XII. 

MORBID EFFECTS OF FIEST DENTITION. 

Dentition is not, in itself, a morbid process, but a healthy 
physiological act. It would be strange, therefore, if it neces- 
sarily involved disorder of function and serious consequences 
to the subject. 

The truth is, that when naturally performed, under the fa- 
vorable circumstances of sound constitution and good health 
on the part of the child, the cutting of the teeth is performed 
without pain or any collateral evil, these organs appearing 
in their place, without any previous unpleasant sensations to 
attract attention to their progress through the gum. It is 
thus that the domestic animals perform dentition; and. many 
children complete theirs with no more perceptible inconve- 
nience. 

More generally, however, the child experiences, at least 
with some of its teeth, more or less suffering of a local kind, 
and in many cases the pain is attended by sympathetic irri- 
tation of a grave, and not unfrequently, of a fatal character. 

It is important to know that, however large may be the 
proportion of painful, in comparison with natural dentition, 
the former are nevertheless to be regarded as accidental mo- 
difications of the regular and healthy process. Starting with 
this knowledge, we will, of course, be led to inquire into the 
causes, so general and so potent, which effect the changes in 
question, and to devise means and management most proper 
for escaping or annulling them. 



196 MORBID EFFECTS OF FIRST DENTITION. 

Does painful dentition depend upon the pressure exercised 
by the tooth upon the gums? 

If it did, all children would experience suffering and more 
or less collateral morbid effects. For although the difference 
of natural sensibility in different children would occasion 
differences in the degree of trouble arising from this cause, 
yet this comparative sensitiveness, being merely natural and 
healthy, could not account for the extreme contrasts ex- 
hibited between easy and simple, and complicated and dan- 
gerous dentition. 

Nor is it at all likely that extreme sensibility would escape 
morbid manifestation during the rapid evolution of infantile 
life, until awakened from its passivity by the evolution of 
organs, themselves not sensitive, (in their healthy state,) pass- 
ing through structures not by any means remarkable for 
this quality, and performing their eruption so gradually as 
to make no sudden demands upon the nervous and vascular 
system, so as to disturb the equilibrium of nervous and vas- 
cular distribution. 

Nor is it consistent with the facts observed in the history 
of dentition that the cause of the suffering is the pressure of 
the fangs of the teeth upon the periosteum of the alveoli. 
Those who adopt this explanation have not considered that 
the shooting of the teeth, characterized by the enlargement 
of the alveolar walls, and the distention of the gums occa- 
sioned by the formation of the body or of the crown of the 
teeth, is an epoch often more dangerous than that of the or- 
ganization of the roots; which besides would do much more 
harm in compressing and binding the soft and pulpy part of 
the tooth than the serous membrane, which performs the 
function of a periosteum and lines the interior of the gum 
and proper cavity of the teeth.* 

* Baumes on First Dentition. 



MORBID EFFECTS OF FIRST DENTITION. 197 

The truth seems to be, that a great number of children are 
born into the world so feebly or disproportionately constituted 
that they are not capable of maturing. Most of these neces- 
sarily perish during childhood, by some of the many forms 
of disease common to that period. Many others, though 
born with sufficient vigor, are reduced by bad diet and de- 
fective management to a condition which readily yields to 
irregular or morbid agents. 

A child may be very feebly organized, and yet may ap- 
pear for a time plump and healthy, but when the vital pow- 
ers come to be tested either by accidental or physiological 
demands upon its energies, the natural feebleness is ascer- 
tained by the development of various morbid phenomena 
indicating the particular location and kind of disability. 

Again, children born healthy are often subjected to priva- 
tions or to injudicious diet and regimen which rapidly alter 
their fluids and tissues, and lay the foundation for serious 
accidents. 

Dentition demands a certain amount of constitutional 
energy to accomplish it. The rapid development of any organ 
does this. The changes which take place at puberty, and 
the evil consequences, to the feeble, of the developments 
then completed, are illustrative of this fact. This demand 
is the severest test of functional and organic completeness 
in the child, and many will not bear it. 

The development of the teeth determines an unusual flow 
of blood to the head. This happens at a time when the brain 
is proportionately large, and undergoing rapid evolution. 
Independently of dentition, this period of life is attended by 
a strong tendency to cerebral affections, and to pulmonary 
and abdominal complications. The nervous and vascular 
systems are, in the child of this age, remarkably active. The 
several organs have to perform not only their functions and 
the preservation of their entireness, but also rapid growth. 



198 MORBID EFFECTS OF FIRST DENTITION. 

Animal life is, therefore, exalted with all its qualities. 
Among these are sensibility and sympathy : the capacity to 
be impressed and to propagate impression. Hence a slight 
cause may produce great local or constitutional effect, and 
disease of any kind may induce sympathetic or constitutional 
disorder apparently much out of proportion to its own in- 
tensity or importance. 

In the older child the relation of secondary to primary 
affections is more equable, and the second dentition is per- 
formed without the occurrence of those serious constitutional 
affections which so frequently attend the first. 

Any unnatural obstacle or impediment to the eruption of 
the first teeth, will tend very materially to augment the pro- 
bability of morbid consequences. A disproportion between 
the teeth and the jaw, or the unusual hardness and impene- 
trability of the gum, are of this nature, and sometimes pro- 
voke local and sympathetic disturbance. 

The appearance of several teeth at once may make a 
larger demand upon the system than it can readily meet, and 
hence cause embarrassment; or, if their dentition be painful, 
the amount of suffering may be too great for the sensitive 
and sympathetic nature of the child, especially if it be con- 
stitutionally feeble. 

The natural symptoms of healthy dentition, are not re- 
markable. An increased flow of saliva is usually noticed, 
though this, perhaps, is not as certainly the consequence of 
dentition as is generally supposed. The mouth of infants is 
generally well supplied with fluids, which, there being no 
teeth to prevent it, will escape more or less from the mouth. 
The child also carries its fingers to the mouth more fre- 
quently, and seems pleased to press a resisting substance 
between its gums. Gentle friction of the gum also seems to 
be agreeable. The gums are noticed to be hot, and the child 
takes the breast frequently. The bowels are generally looser 



MORBID EFFECTS OF FIRST DENTITION. 19.9 

than usual, and the child ordinarily manifests some little 
restlessness, and sleeps less profoundly than previously. 

These symptoms precede the eruption of the teeth by se- 
veral weeks, and seem to depend upon the rapid ossification 
and growth of teeth. After a few days, they often subside, 
to be renewed when the teeth are pressing forward and about 
to penetrate the gum. 

It is common to alleviate these little inconveniences, by 
giving the child a coral, crust of bread, or other hard sub- 
stance, to press upon with its gums. 

Nature is generally a very correct guide as to her own 
wants, and as it is natural thus to allay the sensation of the 
gums at this period it must be right. A priori, however, 
we might have feared that the continual pressure would con- 
dense and harden the gum and make it more impenetrable. 

Inasmuch as nature has not indicated the precise degree 
of resistance proper for the purpose, it would be well to use 
substances which do not possess this quality in an unneces- 
sary degree. 

The French use a stick of marsh mallows, or liquorice root 
dipped in honey, or a sweetened decoction of barley — the 
Germans, a small bag filled with sugar and spices. It is 
doubtful, however, whether the success of this invention for 
quieting the child may not induce the nurse or mother to 
neglect it, and withhold the breast which it would take ea- 
gerly and frequently. Nothing so soothes the infant as the 
frequent lubrication of the mouth with the mother's milk, and 
where nothing in the state of the mother's health or the con- 
dition of her breast forbids this indulgence, it is cruel and 
unnatural to deny it. It may be, too, that the constant use 
of sweet and condimental substances would disorder the sto- 
mach of the child: an accident to be studiously avoided 
during teething. 

The bowels are generally loose during dentition, and even 



200 MORBID EFFECTS OF FIRST DENTITION. 

when the purging is very frequent we must not consider it 
excessive while the child nurses freely, and especially while 
it does not emaciate. 

Costiveness is much more to be feared under such circum- 
stances than purging. It is unnatural, and unless overcome 
by proper treatment will result in irritations, local, and per- 
haps sympathetic, which may not easily be remedied. 

It is always important to restrict a teething child to pro- 
per aliment. The bowels may very readily be irritated, and 
the system is so liable to violent excitement at this time that 
all irritation should be dreaded, especially irritation of the 
abdomen ; for this is the most important part of a child, being 
the centre of the very active processes of nutrition and aug- 
mentation every where going on. This is no time to try ex- 
periments upon the stomach. Nutritious and easily digested 
food, and that which is free from acidity, is to be given, and 
in such quantities as the child is willing to take. Unless, 
indeed, it has been habitually over-crammed and taught to 
eat an unnatural quantity. 

When the mother has milk, this is, of course, the best food 
for the infant ; but it will generally happen that the child will 
require more nourishment than it can obtain from this source. 

In selecting food for it, regard must be had to the condi- 
tion of the child. If delicate and thin, animal food will often 
be indispensable. Beef, mutton, and occasionally a little salt 
meat may be given with advantage. Young meats are ge- 
latinous and less digestible, and should be avoided. 

If the child, on the contrary, be too fat, if it has been over- 
crammed with milk until it presents an appearance similar 
to that of the show calves, stuffed and swollen for exhibition 
at a fair, it should have diet of a far less nutritious kind. 
Farinaceous articles, well diluted with water, will be more 
suitable. 



MOEBID EFFECTS OF FIEST DENTITION. 201 

Milk, if fresh and sweet, generally agrees well with chil- 
dren ; but the milk of the cow is more nutritious than that 
of the mother, and should be diluted. Cream freely diluted 
with water generally agrees better than milk. 

It is common among the rich to thicken the child's milk 
with arrow root, tous les mois, or other concentrated fari- 
naceous food. The consequence generally is that the pa- 
rents are enabled to rejoice over fat babies, and soon to sor- 
row over sick ones. Instead of making the milk of the cow 
more nutritious, it should be rendered less so than natural. 
It is rarely that articles of this kind, even when they are 
what they are represented to be, are fit for children. But 
this is rarely the case. Most of the arrow root, &c, of the 
shops is potato starch.* 

Some parents are in the habit of refusing children flesh of 
all kinds, and indulging them freely in milk and potatoes. 
The result generally is fo fatten the children excessively, 
without providing them with a proportionate amount of mus- 
cular fibre. 

The child should have as much exercise in the open air as 
the circumstances of the parent will admit. All kinds of 
exercise seem to do it good. It is seldom fatigued even by 
very long rides, and rarely fails to acknowledge in its altered 
appearance the good effect of even an hour's exercise in the 
fields. 

Frequent bathing is of great use to children of all ages, 
but even this means requires to be administered with judg- 
ment. The cold bath is a powerful remedy, and cannot be 
used with equal safety and advantage upon all children. 
Those who are ruddy and robust will bear it well; while 
others who are pallid and of cold skins may suffer serious 
injury from it. If after the bath the child shivers for a con- 

* If the milk require the addition of any farinaceous substance, I prefer 
rice flour. 

14 



202 MORBID EFFECTS OF FIRST DENTITION. 

siderable time and remains cool, and if it contracts a dread 
of the water, the temperature should be elevated to meet the 
condition of its sensibilities. 

Of course in cold weather, the water should always be 
warmed in proportion to the necessities of the case. 

When dentition becames complicated with morbid condi- 
tions, directly or indirectly connected with it, the manage- 
ment of it requires far more care and skill. The local symp- 
toms are to be allayed, serious symptomatic affections are to 
be relieved, and the strength of the child to be supported 
through a tedious process, in which the powers of the sys- 
tem are taxed to their utmost capacity. A single mistake 
here will often prove fatal, and it is easy under such circum- 
stances to make mistakes. 

The diseases of dentition are local, those which affect the 
teeth, gums, and mouth — or sympathetic, those which mani- 
fest themselves in other organs. 

The local diseases of dentition are, first, inflammation of 
the gums. These are swollen, hot, redder than common and 
very sensitive. The child will not permit them to be touched, 
and incessantly craves the breast or cold liquids. The con- 
dition of the gum is almost always attended with more or 
less fever and irritation of the intestinal canal. There is also 
an evident determination of blood to the head. The face is, 
flushed, the head hot, the eyes red and watery, the flow of 
saliva profuse, and sometimes the salivary glands are swollen 
and tender. Aphthous exudations are often noticed, and it 
is said, though this must be very uncommon, that abscesses 
sometimes occur at the root of the tongue. 

The fever is generally ardent, and increases and subsides 
with remarkable suddenness. The thirst attending it is very 
great, and a strong tendency to irregular muscular contrac- 
tions or convulsions is generally observed. The sleep of the 
child is uneasy, and frequently interrupted. It frequently 



MORBID EFFECTS OF FIRST DENTITION. 203 

starts and screams, and when awake is usually fretful and 
stupid by turns. 

These symptoms are often very suddenly and effectually 
allayed by freely incising the. gum and capsule down to the 
tooth or teeth, and liberating them from their investments. 
This expedient is generally resorted to whenever the gum 
is elevated and distended, sometimes, however, it is of no 
avail, either because it is not effectually done, or because the 
symptoms to be relieved do not in fact depend upon the 
mere mechanical pressure. 

The French writers make a formidable matter of this little 
operation; and indeed, as practised by some of them, it is no 
trifle, for they make a crucial incision upon the tooth and 
dissect up the flaps of the gum, or else, with a bistoury, com- 
pletely cut off the top of it. 

There is no necessity for such painful and protracted ope- 
rations ; a free incision, until the lancet grates upon the tooth, 
is all that is necessary for the incisors ; and when the double 
teeth are in question, a cross incision may be added. 

The lancet should be carried down to the tooth, or else no 
good will be done. 

The bleeding which results is trifling and salutary ; tend- 
ing to relieve the inflamed and swollen gum. 

It has been objected to this operation, that unless the tooth 
should be very near the surface, the incision will heal and 
the cicatrix will offer more resistance than the original 
structure of the gum. 

The fact is, however, that if such a cicatrix should occur, 
and the symptoms return, it would be very easy to divide 
the gum again ; moreover, a cicatrix is always a feeble tissue, 
which is far less resistant than the natural part whose loss 
it represents. 

Conjointly with the use of the gum-lancet, attention must 
be paid to the bowels of the child. If it be costive, the tor- 



204 MOKBID EFFECTS OF FIEST DENTITION. 

por of the bowels must be relieved by the administration of 
proper purgatives. Of these ; calomel is for several reasons 
by far the most useful, and is equally safe, for occasional ad- 
ministration, with the most innocent of the class. 

In these conditions, the abdominal secretions are always 
vicious, and we have no means so powerful as calomel for 
the restoration of impeded or altered secerning function. 
To a child of a year old, four, and to one of two years, six 
grains should be given at a .single dose ; and, if necessary, its 
cathartic effect insured by the subsequent administration of 
castor oil or magnesia. 

Small doses of calomel are ineffectual, and, if frequently 
repeated, are dangerous. 

Should the bowels be too loose, and the passages thin and 
white, the same medicine similarly administered, or joined to 
a little rhubarb or chalk, will generally check the diarrhoea. 

In these cases, as where constipation exists, the fault seems 
to be in the deficit or altered secretion of the liver, which 
calomel restores. 

The fever will generally abate in proportion as the bowels 
are put right. Should it continue ardent, however, and 
especially if the cerebral plethora should increase or remain 
unabated, a few leeches behind the ears will often prove ser- 
viceable. 

The cold bath, or sponging with cold water, will also allay 
the fever and restlessness. The warm bath may sometimes 
be preferable, and will be equally serviceable. Above all, 
country air and exercise out of doors, are the best means of 
combating the disorders of dentition. 

"Very different," says Mr. Jay,* "was the practice of our 
forefathers, who, misled by the fanciful doctrine of signatures, 
were in the habit of applying to the gums specific ointments 

* Cyclop, of Prac. Med., Art. Dentition. 



MOKBID EFFECTS OF FIBST DENTITION. 205 

made of the brains of hares, or of the combs of cocks, which, 
as old Hartman would have us believe, ' cause the produc- 
tion of teeth without difficulty, and free from accidents.' " 

It is questionable whether we have much right to laugh 
at the metaphysical medicine of our ancestors : certainly our 
posterity will find abundant occasion to ridicule our own. 

We have yet to learn that any ancient theory or practice 
of cure was more utterly absurd than Homoeopathy or the 
cold water treatment. The doctrine of signatures is quite as 
philosophical as mesmerism, and the combs of cocks and 
brains of hares are certainly as efficacious as Hahneman's di- 
lutions. 

Among the local diseases of complicated dentition we must 
enumerate caries of the tooth and abscess of the gum. When, 
from any cause, local or constitutional, caries of the tooth 
takes place, it engenders inflammation of the periosteum, 
which soon extends to the gum. This becomes painful, swol- 
len and tender : an effusion of fluid takes place between the 
fang and its investing membrane, which thus becomes a sort 
of cyst or sac. Finally pus is formed, an abscess appears, 
and the matter is voided, either by a spontaneous or artificial 
opening. 

The continuance of the carious tooth as an irritant will, 
of course, prevent the proper healing of the ulcer, and the 
fungus, so common in carious ulcers, will shoot up. 

"In other cases the pressure of the abscess having produced 
absorption of a portion of the alveolar process at its lower 
part, it effuses its contents through the aperture thus formed, 
and the matter insinuates itself along the surface of the lower 
jaw, and forms an internal tumor near its base. This tumor 
is at first hard and discolored, but in the course of time it ul- 
timately inflames, and bursting or being opened, leaves a 
puckering in the integument, which adhering to the bone, 
remains a permanent blemish. When the diseased tooth, 



206 MOBBID EFFECTS OF FIEST DENTITION". 

which, is the cause of the mischief, is removed before exter- 
nal redness takes place, the tumor ultimately retires, and 
leaves the skin unblemished." * 

A spongy condition of the gums, in which they bleed 
freely at the slightest touch, is sometimes observed in denti- 
tion. Ulceration sometimes attends this condition. Weak- 
ened digestion and consequent imperfect preparation of chyle 
and insufficient nutrition, may be considered the cause of 
this affection. 

Treatment. — Inflammation of the gum may be very much 
abated by the application of a leech to it. In order to do 
this with facility, a thread may be passed by a needle through 
the extremity of the animal, and then it may be enclosed in 
a glass tube. When the inflammation has subsided, the ca- 
rious tooth should be extracted. 

Should an abscess occur from a similar cause, extraction 
must also be resorted to. 

Sponginess and ulceration of the gums, depending upon 
a depraved digestion, must be met by such means as will re- 
store the alimentary canal to the regular and complete per- 
formance of its functions. 

Mild astringent lotions, such as myrrhine and aluminous 
solutions, may be simultaneously employed. 

* Coleys' Diseases of Children. 



CHAPTER XIII. 

SYMPATHETIC DISEASES OF DENTITION. 

A vast number of diseases have been described by different 
authors as the results of dentition. The recapitulation of them 
would show a crowded list of formidable complaints, from 
which it would seem that no child could escape. Dentition 
appears in this exhibition as the Pandora's box from which 
all manner of evils are successively let loose to worry and 
destroy the devoted infant. Without pretending to enume- 
rate the forms of disorder attributed to teething, we offer the 
following as a specimen : Vomiting, anorexia, diarrhoea, cho- 
lera, costiveness, increased or diminished urine, urethral or 
vaginal discharge, with painful micturition ; dry cough, dys- 
pnoea, catarrh, pneumonia, spasmodic affections of the face, 
limbs, glottis, &c, insomnia, agitation, and fright on awaking ; 
epilepsy, somnolence, stertor, coma, transient palsy of the 
arms and legs, ophthalmia, hydrocephalus, marasmus, erup- 
tions, especially about the head and face, swelling of the 
hands and feet, enlargement of the cervical, femoral, and me- 
senteric glands, and other scrofulous affections. 

Although any of these disorders may, and all of them do 
occur during dentition, it does not by any means follow that 
teething is the cause of them. The mucous membranes of 
children are very liable to inflammatory affections, and their 
brain is very liable to sympathize with these and other dis- 
orders. Moreover, the process of dentition would certainly 
afford an awkward complication to any of these forms of dis- 



/ 



208 SYMPATHETIC DISEASES OF DENTITION. 

order occurring simultaneously with it, or provoked by ac- 
cident during the progress of teething. No doubt, also, den- 
tition itself, especially if obstructed, or otherwise irregular or 
morbid, may become the exciting cause of any disorder to 
which the child may at the time happen to be most prone. 

Should inflammatory affections of mucous membranes oc- 
cur during dentition, the treatment should be regulated by 
the nature of the particular case, and the judgment of the 
physician. It would always be well, however, to examine 
the gums carefully, and to incise them freely if they be at 
all swollen. This can do no harm, and sometimes will result 
very happily. 

Yery often, perhaps most frequently, the mucous affec- 
tions are not inflammatory, but consist in a kind of morbidly 
increased sensibility, which we call irritation. The irrita- 
bility of the stomach, the vomiting and purging, are frequently 
of this kind, and would only be aggravated by antiphlogistic 
treatment. 

Proper purgatives, especially calomel: proper food and 
sufficient exercise will be found to accomplish all, or nearly 
all, that art can do for the relief of such conditions. 

The cough which accompanies dentition is also due to the 
irritability of the mucous membrane, and needs no special 
treatment. 

The inexperienced practitioner must be careful, however, 
not to confound this condition with proper catarrh or pneu- 
monia. Children are liable to severe pulmonary disorders, 
which require the most prompt and vigorous treatment, and 
which it would always be serious and often fatal to neglect. 

The febrile disturbance, the quick, short respiration, the 
distended nostril, and the indescribable, yet intelligible ap- 
pearance of the little patient, will render mistake entirely un- 
necessary. 

The most serious complication of dentition is undoubtedly 



SYMPATHETIC DISEASES OF DENTITION. 209 

a gastrointestinal disorder ; which has acquired the name of 
Cholera Infantum. 

This disease occurs only in hot weather, and is almost pe- 
culiar to cities. Occasional cases of it, however, occurring 
in warm, unsheltered places in the country, are sufficient to 
show that its urban character is dependent simply upon the 
heat of cities, which especially at night is very much greater 
than is experienced in rural situations, unless very unfavor- 
ably circumstanced. 

This disease seems closely connected with dentition, for 
although very young infants may be attacked by it, they 
are by no means so liable as those who have completed their 
first year. Hence the familiar danger of the child's " second 
summer." 

The disorder usually commences by purging; frequently 
as the immediate consequence of some indigestible substance 
taken into the stomach, but often without any known ex- 
citing cause. The matters passed at first are light green — pre- 
senting somewhat the appearance of chopped grass, and gra- 
dually becoming paler until they are of an extremely pale 
yellow or absolutely white. Vomiting, especially after 
swallowing liquids, generally attends the diarrhoea, and com- 
monly fever of a fickle, fluctuating character also occurs. 

The child emaciates very rapidly, and in a few weeks or 
days will be reduced to a mere skeleton, and be too feeble 
to stand alone. The brain and nervous system become tor- 
pid, the muscles relaxed, the child somnolent and stupid, 
and death, from cerebral congestion or convulsions, closes 
the scene. 

The disease is sometimes acute and rapid in its develop- 
ment and progress, at other times chronic. The only medi- 
cinal agent which is uniformly beneficial in this disease is 
calomel. The nature of the alvine discharges evinces a de- 
ficiency or entire absence of bilious matter. A full purga- 



210 SYMPATHETIC DISEASES OF DENTITION. 

tive dose of calomel rarely fails to restore this secretion, and 
all the symptoms are alleviated by it. 

From the fact that this medicine can be given in small 
bulk, that it is almost tasteless, and that it will remain in 
the stomach which rejects all other drugs, it is peculiarly 
adapted to the condition in question. As this adaptation 
makes it the most available, it is exceedingly fortunate that 
its medical qualities make it by far the most efficient of 
remedies in this disease. 

Some writers recommend it to be given in small doses, fre- 
quently repeated, but while there is no advantage to be 
gained by this procedure, there is risk incurred of mercu- 
rializing the child ; which would generally be fatal to it. It 
is true that this rarely occurs ; but some children have a pe- 
culiar constitutional susceptibility to mercurial action, and it 
is better to risk nothing unnecessarily in this respect. 

The dose which experience leads me to employ, is from 
two to ten grains, according to the age of the child and the 
condition of its sensibility. It may be repeated several times 
within a week, or less, if necessary. 

Alkaline medicines, soda, potassa, magnesia and chalk, are 
also useful in neutralizing acid, and perhaps, also in correct- 
ing the disordered condition of the mucous membranes. 

A cautious, yet bold use of opium, will often render ser- 
vice which no other treatment will afford. It quiets the 
stomach, soothes irritation, checks the diarrhoea, and gives re- 
freshing sleep. 

The great difficulty in the treatment of this disease arises 
from the fact that it is the result of causes which continue to 
act; so that the disorder is constantly reproduced. 

These causes are heat and dentition ; and it is often im- 
possible to cure the child while the causes continue to act. 

In large well ventilated rooms it is often possible, even in 
cities, to procure for the child a temperature which is salu- 



SYMPATHETIC DISEASES OF DENTITION. 211 

tary; but even under these circumstances it is not always 
possible to do so. When, therefore, the little patient is the 
child of poverty, imprisoned in the small room of a small 
house, shut up in a court or alley, it is almost impossible to 
rescue it from death. 

The most certain of all remedies is to take the child to the 
country. There, proper medical treatment will rarely, or 
never, fail to cure the disease. Children in apparently the 
last degree of prostration are sometimes revived as by mira- 
cle, by the cool air of the country. 

But when we say country, we do not mean a hot room 
near the roof of an unshaded tavern fronting on a turnpike 
road, where numbers of sick children are shut up together, 
in a temperature perhaps higher than that of the spacious 
city mansions from which they have been hastily removed. 
Shade and green grass are essential. There must be no bare 
surface to reflect the heat, and there must be shade where the 
child may be exercised, and where it may be conveyed in 
the middle of the day, when country houses are as warm, 
and often, from their size and construction, warmer than city 
dwellings. 

Convulsions very frequently occur during dentition. They 
are of an epileptic character. The symptoms are a fixed 
stare and often distortion of the eyes, insensibility and fre- 
quent irregular contraction and expansion of the muscles, 
generally of the limbs and face. The jaws are firmly 
clenched, and the saliva is ejected in froth from the lips. 

This is a very frightful and generally very alarming affec- 
tion, though not very often fatal. 

Convulsions during dentition may be excited by several 
causes. The first and the most common is the eating of 
crude and indigestible matters ; secondly, fever ; and thirdly, 
the irritation of the teeth themselves ; often two, and some- 
times all three of these causes act together. 



212 SYMPATHETIC DISEASES OF DENTITION". 

The convulsion generally passes off in a few minutes, but 
another will occur unless the cause be removed. Sometimes 
it will continue with little or no mitigation for hours, and 
sometimes it continues until the death of the patient. In or- 
der to relieve the spasms, it is generally sufficient to put the 
extremities in warm water and pour cold water on the head ; 
if this do not speedily accomplish the end, more active means 
must be used, and such as look to the removal of the cause. 

If spontaneously, or by the use of the bath, the convulsion 
subsides, we should carefully inquire into the cause of it. If 
the child has eaten anything, it should be immediately vo- 
mited, and indeed this can rarely be amiss ; for it is often im- 
possible to elicit the necessary information, until the presence 
of the ejected matters exhibits the cause of irritation. 

If there be high fever, which will not yield to the influence 
of an emetic, or which is so grave of character as to demand 
more immediate remedies, the child should be bled in order 
to relieve the brain, which is suffering from the rapid circu- 
lation of blood through it. This may be done either by the 
lancet or by leeches. 

If the gum be swollen and tense, and the child seems to be 
suffering from this cause, a free incision will often relieve 
the tendency to spasm, by allaying the local, and with it the 
cerebral irritation. 

Finally, if the child be costive, its bowels should be im- 
mediately opened by injection, and subsequently by a pur- 
gative dose of calomel. 

Dr. Underwood describes a peculiar swelling of the hands 
and feet as a casual attendant upon dentition. He con- 
sidered it, however, as rather beneficial than otherwise, as it 
ceased spontaneously with the appearance of the teeth. 

Cutaneous eruptions frequently occur during dentition, but 
they are of little consequence, as they spontaneously disap- 
pear, and, in some instances, may be considered as a salutary 



SYMPATHETIC DISEASES OF DENTITION. 213 

diversion made by nature for the relief of the brain. Some- 
times, however, they are so disagreeable, that some efforts 
are demanded for their relief. Most, or perhaps all of them 
occur independently of dentition, and as a description of 
them would be tedious, and, without plates, unsatisfactory, 
and as they are all fully described in works specially upon 
this subject, it will only be necessary to name them here; so 
that the student may seek farther information from writers 
upon cutaneous disease. 

The principal varieties are, an erythematous efflorescence 
behind the ears, called, in medical language, intertrigo; 
crusta lactea; the several varieties of strophulus; small 
phlyctenge, or blisters, and evanescent red spots. 

Although these eruptions occur frequently during denti- 
tion, they are by no means peculiar to this period, and it is 
difficult to show that they are necessarily connected with the 
cutting of the teeth. 

Intertrigo. 

This is a kind of erythemic or superficial inflammation of 
the skin, generally attended with some exudation of a semi- 
purulent matter, occurring behind the ears. "When the two 
excoriated surfaces rub upon each other, the result is fre- 
quently a very ugly superficial ulcer. The disease can be 
readily cured by the use of absorbent or "drying" powders. 
All moist applications do harm. A most valuable prescrip- 
tion for this and similar conditions of the skin is a powder 
composed of two parts of lapis calaminaris and one part of 
calomel rubbed together in a mortar. This is to be freely 
dusted upon the sore by means of a little raw cotton, several 
times a day. It will rarely fail of success. 

There is an opinion very prevalent that it is hazardous to 
dry up these eruptions, but there is no ground for this sup- 
position. 



214 SYMPATHETIC DISEASES OF DENTITION". 

Crusta Lactea or Milk Crust, (Porrigo Laryalis.) 

This eruption appears with white vesicles, speedily pass- 
ing into dark-colored scabs, itching and ichorous, and fre- 
quently covering a large part of the face, head, and some- 
times other parts. 

The eruption is very ugly and unpleasant, but it is rarely 
injurious to the child. The little patient is generally plump 
and hearty. Indeed, the disease seems rather to depend 
upon a plethoric state, than upon any morbid condition of 
an important nature. The teething is not impeded by it. 

Crusta Lactea is often obstinate, and of some months' du- 
ration. The only serious attendant upon the disease is the 
itching, which is sometimes so annoying to the child as to 
cause it to fall away, and become sallow, &c. 

No treatment is required, or, rather, none does it much 
good. The bowels should be kept free, and the itching al- 
layed by warm bathing, lotions of weak spirit and water, 
and weak solutions of Sul. Zinc. 

Where there is much discharge from beneath the scabs, 
the drying powder already mentioned is a good application. 
As a general rule, the less we do to cure this affection the 
better. Time will certainly restore the child its natural skin ; 
medicine might, and if persevered in, would destroy its ap- 
petite, tease its stomach, enfeeble its health, and, after all, 
produce no effect upon the eruption, except, perhaps, to 
make it worse. 

Strophulus, Tooth Rash, Red Gum. 

This is an eruption very common to nursing children. It 
consists of red or white and itchy papulae evolved upon the 
face and lower limbs, disappearing and returning, and end- 
ing generally in the throwing off of a kind of powdery des- 
quamation. 

The papula? present differences in size and appearance, 
which have given origin to different designations. When 



SYMPATHETIC DISEASES OF DENTITION". 215 

vividly red, prominent, scattered over the cheeks, face, arms, 
and dorsal aspect of the hands, and intermingled with ery- 
thematous patches of varying extent, it is called Strophulus 
Intertinctus, (Eayer.) 

"When the papulae are white, large, and without surround- 
ing redness of the base, the affection is called Strophulus 
Candidus, (Willan.) 

When the papula? are very thick, smaller and confluent, 
"Willan calls it Strophulus Gonfertus; and, finally, S. Volati- 
cus, when it occurs in circular patches, or clusters, here and 
there, on the surface. All these forms of strophulus may 
affect the child at the same time. 

It is not by any means a serious affection, though it some- 
times torments the child by the itching it causes. To allay 
this, we may use the cold or warm bath, purgatives, and 
cool dressing; for the sufferings of the child may be very 
unnecessarily aggravated by warm clothing, especially at 
night. 

The disease spontaneously declines, in a few days or weeks, 
leaving behind it no traces of its previous existence. 

Phlyctence are vesications or blisters of different sizes, re- 
sembling scalds or burns. They soon disappear, and require 
no special treatment. 

There are a number of rashes seen during dentition, which 
it is not necessary for us to describe particularly. Scrofu- 
lous children are subject, during dentition, to the lymphatic 
disorders peculiar to their constitution, such as is manifested 
by the swelling of the cervical, inguinal and mesenteric 



The treatment of these, and kindred affections, must turn 
upon the means of invigoration previously referred to when 
considering the constitutional vice upon which they depend. 
Proper nutriment, exercise, clothing, &c, will do all that can 
be expected from external agents. 



216 SYMPATHETIC DISEASES OF DENTITION". 

Second Dentition. 

The cutting of the second set of teeth is commonly accom- 
plished without inconvenience, either of a local or constitu- 
tional character ; with the exception of the wisdom teeth, 
which being often crowded, not unfrequently occasion a great 
deal of suffering, such as acute local pain, inflammation of 
the gums and adjacent tissues, fever, violent headache, oph- 
thalmia, &c. This suffering has often been mistaken for that 
accompanying other affections, such as neuralgia, intermit- 
tent fever, and rheumatism. Abscesses near the angle of 
the jaw may occur under these circumstances. 

Of course the treatment, under these circumstances, would be 
to liberate the impeded tooth by a free incision, or even, under 
certain conditions, to extract it. The inflammation of the soft 
parts must be combated, if necessary, by antiphlogistic means. 

Third Dentition. 

A number of well authenticated cases of partial and even 
complete dentition, occurring in very old persons, are re- 
corded in the books. In one instance, given in the Edin- 
burgh Medical Com., vol. iii., the subject of this late teeth- 
ing suffered very severely. 

The patient, in this instance, was sixty years old, and en- 
tirely toothless. At this time he experienced very severe 
pain in his gums and jaws, which at length amounted to ex- 
cruciating torture ; but at the end of twenty- one days from 
the beginning of his sufferings, he was compensated by the 
appearance of a complete new set of teeth. 

With regard to the constitutional effects of this abnormal 
dentition, Prof. Harris, who relates two cases of this kind as 
having occurred under his own observation, remarks: "It 
would seem that the efforts made by nature for the pro- 
duction of a third complete set of teeth, are usually so great, 
that they exhaust the remaining energies of the system ; for 
occurrences of this kind are generally soon followed by death." 



CHAPTEE XIV. 

EFFECTS OF DISEASED TEETH AND GUMS UPON" THE GENEKAL 

HEALTH. 

That diseased conditions of the teeth and the structures 
adjacent to them, do exert a most pernicious influence upon 
the general health, is a fact as well established as any other 
medical observation ; yet the medical profession seem, as yet, 
with very few exceptions, entirely careless of it. 

We are not apprized that the subject is ever alluded to 
by lecturers on the practice of physic, when recapitulating 
to their classes the causes of functional disturbance and con- 
stitutional suffering ; it is not noticed in the many text-books 
on practice ; and, certainly, however frequently the physician 
may look into the mouths of his patients, it is very rarely 
that his comprehensive glance perceives anything worthy of 
note in the decaying organs of mastication. 

It is full time that practitioners of medicine should per- 
ceive the importance of the teeth and of their diseases ; but 
until they do so, it is the more important that the dentist 
should be able to point out the causes of obscure disease, 
which the physician has in vain endeavored to discover, sim- 
ply because he has sought for it everywhere but in the right 
place. 

It might be granted, a priori, that if physiological condi- 
tions of the teeth, owing to their peculiar position, associa- 
tion, and history, may exercise powerful influence upon the 
15 



218 EFFECTS OF DISEASED TEETH AND GUMS. 

health of other organs, pathological conditions of these same 
teeth cannot be entirely harmless. 

Again, if we would examine the structure of a tooth, and 
perceive how completely its sensitive part is enclosed in an 
unyielding bony case, we might readily infer from the con- 
sequences of compression in other parts, that the swollen 
and inflamed pulp, &c., would be exceedingly painful. If, 
too, we would regard the close connexion existing between 
the teeth, the rapidity with which the flash of sympathetic 
pain darts along the nervous cords which vitalize them, and 
the intolerable and protracted suffering which ensues, upon 
even trifling irritation of these sensitive filaments, and re- 
member that pain itself is fully capable of deranging the 
whole economy, and inducing serious and fatal disorder, we 
might, without the aid of much reflection, adopt the very ra- 
tional conclusion that the diseases of the teeth must be of 
considerable consequence to the entire organization. "We 
might, also, with similar propriety, conclude that the teeth 
were not made merely for ornament, and that mastication 
and insalivation are something more than mere forms of in- 
troduction to the stomach; that they are important to diges- 
tion, which is important to the entireness of organs and the 
performance of function, and that if mastication, and the in- 
salivation accompanying it, be imperfectly performed, some 
corresponding imperfection of digestion must result. We 
might also infer, from the known consequences of long-con- 
tinued morbid influences, however unimportant in their im- 
mediate action, that disturbance of digestion, constantly re- 
peated, must, in time, develop evils of a serious character. 

The old pathological maxim, "ubi irritatio ibi fluxus,"* 
is fraught with a valuable lesson to the medical practitioner. 
It is true that the nervous, and to a certain degree, even the 

* " Where there is irritation, to that part will be the flow." 



EFFECTS OF DISEASED TEETH AND GUMS. 219 

vascular forces hurry to the part which throws out the sigual 
of distress, and all the floating energies of the system are di- 
rected to the relief of the suffering. If it can be readily ac- 
complished, the equilibrium of the system is soon restored, 
and no perceptible inconvenience results. But if from the 
impracticable nature of the tissue or organ affected, but little 
relief can be given, and if the efforts of nature to accomplish 
cure or removal of the part, end only in accumulating about 
it an uncommon amount of sensibility, increasing the irrita- 
tion and demanding yet more of constitutional effort to com- 
bat it, the consequence must be such a diversion of nervous 
influences from other parts as to weaken their force of action, 
and to embarrass their functions. 

In short, it is easy to understand that when the first move- 
ment towards constitutional derangement has been made, if 
the cause continue to act, each accession of morbid condition 
must aggravate and extend the evil, and hence it is that causes 
in themselves very slight may, if long continued, from the 
influence of sympathy and the accident of relations, induce 
morbid conditions of the most serious character. 

The remarks of Mr. Koecker upon this point are so sensi- 
ble and so well expressed, that no apology will be necessary 
for introducing them here at some length. 

Mr. Koecker observes that, "to form a more distinct con- 
ception of the very powerful morbific influence which the 
diseases of the teeth and their contiguous parts must unavoid- 
ably produce upon the general constitution, it is necessary 
to consider the peculiarity of the structure and functions of 
these parts. 

"The extremely hard and dense structure of the bony 
parts of the teeth, and the great arterial activity and nervous 
irritability of their lining membranes, which can so power- 
fully, and for so long a time, defend the teeth against general 
local and morbid influences, are also causes of their pro- 



220 EFFECTS OF DISEASED TEETH AND GUMS. 

ducing very extensive morbid effects upon the whole system. 
The functions of the teeth as well as of the gums, when in a 
healthy state, act as powerful stimuli towards their preserva- 
tion, but when these parts are diseased or affected with dis- 
order of any kind, they become constant causes of irritation 
upon them as well as upon the general health. The bony 
structure of the teeth, however, having in itself but little 
self-restoring power, and their peculiar functions being much 
less favorable to this natural process than those of any other 
part of the body, and the teeth and their gums, periostea and 
sockets, being altogether dependent upon each other, this 
power is much more constantly and in a much higher degree 
required, and seems to be much more exerted by these than 
by any other structures, and the more these powerful efforts 
are incapable of curing the dental diseases, and resisted in 
their efforts to remove their causes, the more active is the 
constitution in its attempts to resist the progress of such dis- 
eases, whilst at the same time a considerable portion of ge- 
neral health and strength is consumed in the struggle. 

"Diseases in the bony structure, and indeed of the teeth 
and gums generally, when yet in their incipient stage and 
without being influenced by any other causes than the local 
disorder itself, produce no greater constitutional effects than 
other local maladies ; but with this difference, that their self- 
curative action is exerted in a proportion corresponding to 
the peculiar structure, functions and relations of these parts, 
and therefore comparatively much greater and longer con- 
tinued than that produced by diseases of other parts or bones. 
In this state they proceed very slowly, and their morbid ef- 
fects can only be detected by the most minute attention. 

" The general system, however, in the meantime being of- 
ten disturbed, the caries will be found to proceed much faster 
towards the cavity of the teeth, and the inflammation of the 
gums to increase. In that event, any constitutional disorder 



EFFECTS OE DISEASED TEETH AND GUMS. 221 

is competent to aggravate the local one, whilst the latter, also, 
in its turn, greatly excites and augments the former. At this 
period it may be still taken as a general rule, that the mor- 
bid influences of general disease upon the dental maladies 
are more powerful than those of the teeth upon the general 
system. 

" The teeth having been deprived of their vitality by the 
destruction of their lining membranes, are not only rendered 
useless, but are converted into lifeless incumbrances upon the 
system, which produce, by their mechanical and chemical 
irritation, an action similar to that effected by gangrene or 
mortification in other bones, by means of which, nature at- 
tempts to throw off the dead part. 

" The parts surrounding such dead teeth, viz. : gums, pe- 
riostea, sockets and maxillary bones, are thus involved in se- 
rious disease, inflammation gradually extends over the whole 
of these parts, and a strong effort appears to be made to ef- 
fect the expulsion of the decayed teeth, now become dead 
and offending bodies. But although nature might succeed in 
thus removing almost any other soft or hard part of the body 
of equal dimensions, in a few weeks or months, a space of 
from five to ten years, and sometimes a much longer period 
is required for the removal, by the same natural power, of a 
dead tooth. 

" As long as the primary diseases are principally confined 
to the teeth themselves, and in these instances where they are 
the proximate local causes of diseases of the mouth without 
supposing the existence of many dead stumps of teeth, so 
long may we look for those acute symptoms and effects which 
have been stated, and see them change alternately from one 
form of disease into another, but after that period, or when 
the local maladies having originally commenced in the gums, 
periostea, alveoli, and maxillary bones, shall have extended 



222 EFFECTS OF DISEASED TEETH AND GUMS. 

to a certain degree, a total transition into a permanent 
chronic state of the disease takes place. 

" In such a state of disease nature seems exclusively and 
actively engaged by producing inflammation and suppura- 
tion in extricating the mouth from all the morbid causes ef- 
fecting the diseased parts, such as dead roots, and stumps, 
tartar, and teeth which are loose or irregularly situated. 
The sanitive power of nature, being, however, very rarely 
competent to effect such a cure, the various diseases of the 
gums, periostea, alveoli, and maxillary bones are exaspe- 
rated, and for the most part terminate in a state of suppuration 
and mortification." * 

"When the chronic condition here described has been fairly 
reached in the progress of disease, the sensibility of the parts 
is much diminished ; the gums and periostea are thickened 
and callous, and the continual discharge sufficiently depletes 
the vessels, to relieve them of the suffering incident to in- 
flammatory engorgement. All resistance to devastation of 
the dental arch, seems to cease, and the parts are abandoned 
to rapid destruction. In the meantime, the patient congratu- 
lates himself that his teeth have ceased to ache, and conse- 
quently gives himself no trouble about them. Inflammation, 
suppuration and caries now spread along the dental arch 
until every tooth is broken down and every root has become 
a permanent irritant, provoking a constant purulent dis- 
charge from the soft parts about it. 

The food is no longer chewed, and every thing which 
passes through the mouth is mixed with a vitiated compound 
of saliva, mucus, pus and blood, which descends to the sto- 
mach to mingle with the gastric juice and deteriorate the 
quality of that most important fluid. 

The absorbents, too, are constantly at work, and the dis 

•Koecker, Princ. Dental Surgery. 






EFFECTS OF DISEASED TEETH AND GUMS. 223 

solved fragments of carious bone, &c, are constantly thrown 
into the current of the blood. 

The alveoli cannot escape the general ruin. Involved in 
the all-pervading inflammation,, they also suppurate and 
break down, and not unfrequently the maxillary bones and 
the antrum are also involved in disease. 

Dyspeptic symptoms, marasmus, cough and other pectoral 
symptoms, violent neuralgic affections of the face, great ner- 
vous depression, hysterics or hypochondriasis, may be ex- 
pected to attend such conditions of the teeth. 

The dyspepsia is easily accounted for. In the first place, 
the food is badly prepared for the stomach ; 2d, the fluids of 
the mouth, constantly trickling into the stomach, impair its 
tone and vitiate its solvent secretion ; and 3d, the continual 
demand made upon the system by the vain efforts which na- 
ture makes to cure the diseases of the teeth, and also by the 
frequent and severe pain, diminishes- the nervous influence 
which the stomach receives, and impairs its powers. 

Every one is aware that when the stomach is full,, there 
takes place in that organ such a concentration of nervous 
energy as is sensibly felt by its loss, in other parts of the 
body. Hence the drowsiness and the indisposition to men- 
tal and physical effort experienced after a hearty meal. 

It is also well known that anything which attracts from the 
stomach this accumulated nervous power, impairs appetite 
and digestion. 

Extraordinary emotions/ powerful intellectual efforts, ve- 
nereal excesses, &c, all act in this way upon the digestive ap- 
paratus. Pain, also, wherever located, produces a similar 
effect, and the impairment from this cause will be important 
in proportion to the frequency and continuance of the suf- 
fering. 

In these several facts we have sufficient reasons for the 



224 EFFECTS OF DISEASED TEETH AND GUMS- 

indigestion which so frequently attends extensive diseases of 
the teeth. 

Marasmus, or gradual emaciation, is but a consequence of 
the insufficient nutrition attending dyspepsia. 

Cough and other pectoral symptoms, may result as the conse- 
quence of any prolonged irritation, especially if digestion be 
impaired. The mucous membrane of the larynx, trachea, 
and lungs sympathizing with similar structures and parti- 
cipating in the common defect of nutrition. 

Neuralgic affections of the face, head, audneck are occasioned 
by the continual irritation of the extremities of the dental 
nerves and the propagation of it to the trunk and branches 
of the great fifth pair or trifacial nerve. 

Depression of spirits, hysterics and hypochondriasis result from 
continual nervous irritation, and the debility of nerve which 
results from long- continued over action. Indigestion also 
is a powerful cause of the melancholy or hysterical condition 
so often observed in these cases. 

Epilepsy and other affections not enumerated above, some- 
times occur as the result of dental irritation, as will be shown 
by the following cases narrated by Dr. Rush (Med. Repos. 
vol. 6, p. 285:) 

Case 1. " Some time in the month of October, 1801," says 
Dr. Rush, "I attended Miss 0. C. with a rheumatism in her 
hip joint, which yielded for a while to the several remedies 
for that disease. In the month of November it returned 
with great violence, accompanied with a severe toothache. 
Suspecting the rheumatic affection was excited by the pain 
in her tooth, I directed it to be extracted. The rheumatism 
immediately left her hip, and she recovered in a few days. 
She has continued ever since to be free from it. 

" Soon after this, I was consulted by Mrs. T. R., who had 
been affected for several weeks with dyspepsia and tooth- 



EFFECTS OF DISEASED TEETH AND GUMS. 225 

ache. Her tooth, though no mark of decay appeared in it, 
was drawn by my advice. The next day she was relieved 
from her distressing stomach complaints, and has continued 
ever since to enjoy good health: from the soundness of the 
external part of the tooth, and the adjoining gums, there was 
no reason to suspect a discharge of matter from it had pro- 
duced the disease in the stomach." (Doubtless it was due to 
the irritation and the consequent deviation of nervous influ- 
ence to the suffering parts.) 

Case 2. (Dr. Eush.) Some time in the year 1801, I was 
consulted by the father of a young gentleman in Baltimore 
who had been affected with epilepsy. I inquired into the 
state of his teeth, (an inquiry which is even yet very unusual 
in such cases, but which serves to show the superiority of 
Dr. K. in judgment and" comprehensiveness of thought,) and 
was informed that several of them in his upper jaw were 
very much decayed. I directed them to be extracted, and 
advised him afterwards to lose a few ounces of blood at any 
time when he felt the premonitory symptoms of a recurrence 
of his fits. He followed my advice, in consequence of which 
I had lately the pleasure of hearing from his brother that he 
was perfectly cured. 

In commenting upon these cases, Dr. Eush remarks: 
"I have been made happy by discovering that I have 
only added to the observations of other physicians in point- 
ing out a connexion between the extraction of decayed and 
diseased teeth, and the cure of general disease. Several cases 
of the efficiency of that remedy in relieving headache and 
vertigo, are mentioned by Dr. Darwin. Dr. Grater relates 
that M. Petit, a celebrated French surgeon, had often cured 
intermittent fevers which had resisted the bark for months 
and even years, by this prescription." (These cases must 
have been merely irritative fever, appearing, as it generally 
does, with exacerbations depending upon constantly recurring 



226 EFFECTS OF DISEASED TEETH AND GUMS. 

circumstances, such as the stimulus of light, food, exercise, 
&c. They were not true intermittents.) He also quotes 
from the work of Petit, two cases; the one of consumption 
(apparently) the other of vertigo, both of long continuance, 
which were suddenly cured by the extraction of two decayed 
teeth in the former, and of two supernumerary teeth in the 
latter case. 

In the second number of a late work entitled "Biblio- 
theque Germanique Medico- Chirurgicale," there is an account 
by Dr. Seibold of a young woman who had been affected for 
several months with great inflammation, pain and ulcers in 
her right upper and lower jaws, at the usual time of the ap- 
pearance of the catamenia, which were always deficient in 
quantity. Upon inspecting the seats of these morbid affec- 
tions, the doctor discovered several of the molares in both 
jaws to be decayed. He directed them to be drawn, in con- 
sequence of which the woman was relieved of the monthly 
disease in her mouth, and afterwards had a regular discharge 
of her catamenia. 

These facts, continues Dr. Eush, though but little attended 
to, should not surprise us, when we recollect how often the 
most distressing general diseases are brought on by very in- 
considerate inlets of morbid excitement into the system. A 
small tumor concealed in the fleshy part of the leg, has 
been known to bring on epilepsy. A trifling wound with a 
splinter, or a nail, even after it has healed, has often induced 
a fatal tetanus. "Worms in the bowels have produced inter- 
nal dropsy of the brain, and a stone in the kidney has exci- 
ted the most violent commotions in every part of the system. 
Many hundred facts of a similar nature are to be met with 
in the records of medicine.* 

* I met with a remarkable case of this kind a year ago. A wagoner be- 
tween 40 and 50 years of age, a very athletic man, had been engaged on the 
day previous in lifting some logs of wood, and perceived a little blood upon 



EFFECTS OF DISEASED TEETH AND GUMS. 227 

When we consider how often the teeth, when decayed, are 
exposed to irritation from hot and cold drinks and aliments, 
from pressure, by mortification, and from the cold air, and 
how intimate the connexion of the month is with the whole 
system, I am disposed to believe they are often unsuspected 
canses of general, and particularly of nervous diseases. 
When we add to the list of these diseases the morbid effects 
of the acrid and putrid matters which are sometimes dis- 
charged from carious teeth, or from ulcers in the gums, crea- 
ted by them ; also the influence which both have in prevent- 
ing perfect mastication, and the connexion of that animal 
function with good health, I cannot help thinking that our 
success in the treatment of all chronic diseases would be very 
much promoted by directing our inquiries into the state of 
teeth in sick people, and by advising their extraction in 
every case in which they are decayed. It is not necessary 
that they should be attended with pain, in order to produce 
disease ; for splinters, tumors, and other irritants before men- 
tioned, often bring on disease and death, when they give no 
pain, and are unsuspected as causes of them. This transla- 
tion of sensation and motion to parts remote from the place 
where impressions are made, appears, in many instances, and 
seems to depend upon an original law of the animal eco- 
nomy." 

Tissot, who wrote nearly a century ago, had become 
aware, from observation, of the great importance of diseases 
of the teeth to the general health. He describes toothache 

his finger, though no wound could be seen. Early the next morning he drove 
bis wagon to the city, nine miles distant. On the road he suffered with in- 
tense pain in the finger, and when he reached the city, he was chilly, pale, 
and evidently laboring under great constitutional irritation. The finger 
showed no wound. The pain increasing, he with considerable difficulty 
reached home. Erysipelas appeared, and he died in a few days. 

The season of the year, being winter, precludes the possibility of his having 
been bitten by a serpent He was not intemperate in his habits. 



228 EFFECTS OF DISEASED TEETH AND GUMS. 

as resulting from gout and rheumatism, as connected with 
disordered stomach, and as the result of the presence of nox- 
ious matters in the blood ; which, according to the pathology 
of his day, was the mode of expressing what we mean by 
constitutional vices or disorders. He also mentions inter- 
mittent toothache, which he cured with Peruvian bark ; and 
neuralgic toothache, which was arrested by generous diet 
and wine. 

Modern medicine, or rather, medical writers, have retro- 
graded in some respects, however much they may congratu- 
late themselves upon their progress in others. Microscopic 
somatology but poorly compensates for that close observa- 
tion of living disease upon which our fathers deservedly laid 
so much stress. 

In the Dublin Medical Free Press, I find the following 
case recorded: — 

Case 3. Painful affection of the eye cured by extracting a 
tooth. — Dr. Emmeuch relates a case of this kind. A man 
consulted him on account of a painful affection of one of his 
eyes, which had lasted fourteen years, and occasioned great 
suffering. There was considerable vascularity of the con- 
junctiva and sclerotica, especially around the cornea, which 
structure itself was somewhat opaque and spotted. There 
was a continual flow of tears, with pain, and intolerance of 
light. All these symptoms were greatly aggravated by any 
indiscretion in diet and the use of the slightest stimulus, such 
as a single glass of wine. All kinds of remedies had been 
tried in vain, at different times, and the affection seemed in- 
curable. On examination of the upper jaw, Dr. E. found a 
carious tooth in the side corresponding to that of the affected 
eye. The portion of the jaw around the tooth was painful, 
and very sensitive to the touch. The patient thought that 
the affection of the tooth had begun simultaneously with 
that of the eye. The tooth was drawn, and almost imme- 



EFFECTS OF DISEASED TEETH AND GUMS. 229 

diately afterwards the symptoms relating to the eye began to 
subside, and soon entirely disappeared. The affection of the 
eye was evidently the result of sympathy between the se- 
cond and third branches of the fifth pair of nerves. 

Dr. Eush (Med. Inq. and Observations on the Diseases of 
the Mind, p. 33,) observes that "Irritation, from certain fo- 
reign matters retained in irritable parts of the body, is among 
the causes of insanity." He adds, " I once knew some small 
shot which were lodged in the foot of a school-boy, induce 
madness, several years after he became a man. It (insanity) 
has been brought on, in one instance, by decayed teeth, 
which were not accompanied by pain." 

Mr. Koecker has published a number of cases, forcibly il- 
lustrating the effect of diseases of the teeth upon the general 
health. From these we select the following : — 

Case 4. "Mrs. P., a lady of great respectability, under 
the medical care of Dr. Jule Eucco, of Leicester Square, had, 
some years since, continually suffered from dyspepsia, as 
well as from various kinds of nervous attacks of a very an- 
noying and alarming nature. This judicious physician had 
for a long time suspected the cause, and frequently proposed 
to consult me. By the wish of the lady, however, the den- 
tist of the family was at last sent for, and three or four teeth 
and roots were removed, which, according to the assertion 
of the dental attendant, were all that could be extracted. 
The disease, however, was only aggravated by this inter- 
ference, and the sufferings of the patient increased more and 
more. 

" About six months after, the doctor again urged a meet- 
ing with me on the subject, and at last I was sent for. I 
found the lady laboring under a complete salivation from an 
extraordinary sympathy of all the glands in any way con- 
nected with the teeth. On the previous night, and, indeed, 
for many nights preceding, she had been suffering such vio- 



230 EFFECTS OF DISEASED TEETH AND GUMS. 

lent fits of convulsion as to alarm the whole family. The 
face was affected with an acute erysipelatous inflammation, 
accompanied with headache, as also with considerable de- 
rangement of the digestive functions, such as sickness, vo- 
miting, loss of appetite, &c. By examining the mouth, I 
found that the previous dental treatment had been but very 
partial, and I proposed the removal of every tooth and root 
which, produced irritation. 

"The lady consented immediately to my proposal, and 
the necessary operations were performed on the 8th of Octo- 
ber, 1824, when nine decayed teeth, some of them mere roots, 
were extracted. The patient was requested to rinse her 
mouth frequently with a diluted astringent lotion. By this 
simple local treatment, and by the farther medical care of 
Dr. Eucco, she was perfectly cured in about a week after the 
operation. 

"Very soon after her recovery, the lady was enabled to 
fulfil a promise of marriage which for some time had been 
prevented by her protracted and distressing disease. Since 
that period, she has enjoyed perfectly good health. 

" The farther treatment of the case has, however, been de- 
layed, on the accomplishment of which, of course, the per- 
manency of the cure will depend." 

Case 5. A literary gentleman in the neighborhood of 
London had been for some years under the medical care of 
Mr. J. Derbyshire, of Greek Street, Soho, on account of a 
constant state of derangement of his digestion. 

Much sedentary occupation, and some excessive grief, had 
of late greatly augmented the distressing symptoms gene- 
rally accompanying this cruel disorder. His disease had as- 
sumed the character of hypochondriasis. His spirits were 
so dejected, and the state of his bodily health was so low, 
that he was no longer capable of attending to his ordinary 
business. 



EFFECTS OF DISEASED TEETH AND GUMS. 231 

Having had some conversations with Mr. Derbyshire on 
the influence of disease of the teeth upon the general health, 
that gentleman was induced, at his next visit, to inquire into 
the state of his patient's teeth, and learning that they were 
in a very deplorable condition, he proposed a consultation 
with me on the subject. After a particular examination, I 
found every tooth in the patient's mouth more or less ca- 
rious, or dead, and all the gums and sockets in a very dis- 
eased state. 

On the 27th of May, 1824, twenty-one teeth and roots 
were extracted, all of which were more or less in a state of 
putrefaction — three large grinders only excepted, which were 
either suffering from complicated caries, or producing mor- 
bid irritation upon the other parts, from some other causes. 

The mouth was restored to perfect health in the course of 
about six weeks. During the progress of treatment of the 
diseases of the mouth, the general health improved very sur- 
prisingly ; and after the restoration of perfect health to all 
the remaining teeth, and their relative parts, the patient en- 
joyed uninterrupted good health, and returned to his ordi- 
nary professional avocations. 

Case 6. The following is a letter which was handed to 
me (Mr. Koecker) by Miss B., Manchester Street, London, 
in the beginning of the month of May, 1825. The history 
it gives is, perhaps, one of the most distressing cases of its 
kind, concerning a lady of great respectability and rank in 
Scotland, of about thirty- eight years of age. Its contents, 
indeed, are not less remarkable for the manner in which 
they display the uncommon fortitude of the unhappy suf- 
ferer, than for the striking confirmation which they give of 
the facts which I have detailed, as well as the description I 
have given, respecting the present state of dental surgery. 
Considering this evidence as most useful and important, I 



232 EFFECTS OF DISEASED TEETH AND GUMS. 

beg to submit to the reader the whole of the fair sufferer's 
most interesting and affecting communication. 

"My Dear : I have been so ill since I wrote you last, 

that I have not been able to answer your kind letter. As I 
can express myself to you easier than to a stranger, I shall 
endeavor to give you some idea of my present state, and you 
can give my letter to Mr. Koecker. Constant faint gnawing 
pains in my gums, membrane of my mouth and cheeks, ac- 
companied with considerable swelling of the latter, which 
are always blotched, inflamed, and irritated, just in the way 
some people's faces are affected when suffering tooth-ache ; 
my very nose is swelled and inflamed, and the muscles of 
the under part of my face so contracted and drawn upwards, 
that I cannot swallow any thing but liquids. My mouth is 
contracted and full of slimy saliva. In bed I have constant 
twitches in my gums, like what I could figure electricity. 
Sometimes my gums and face burn like fire, and soihetimes 
feel as if every nerve and blood-vessel were filled with ice, 
and the sheets near my mouth are wet with saliva. All these 
sensations often run down behind my ears, to my neck and 
arms ; and at these times I have a great hurry and agitation 
of spirits, and aching across the breast and heart. To me, 
one of my greatest tortures is the extraordinary inflation of 
gums, particularly towards the roof of my mouth. They 
feel as if they absolutely tore from the bone, hove up, as it 
were with the wind, and my jaws feel twice too large for my 
mouth, the pressure against my face is such. The same sen- 
sation often proceeds to my cheek bones, which increases 
the swelling of the muscles and the dragging up of the under 
jaw. 

"I must now go back in my history, that Mr. Koecker may 
know the progress of the last five years of my continued 
misery. But, unluckily, I fear it is impossible to make any 
one understand my sufferings, they are so various and com- 



EFFECTS OF DISEASED TEETH AND GTTMS. 233 

plicated. You know I always blamed my teeth, as the cause 
of all my sufferings ; but I am now convinced that the disease 
is in my gums and remains of the alveolar processes ; and as 
I was told that was a part of his profession Mr. Koecker was 
supposed to be very skilful in ; it makes me very anxious to 
have his opinion. You will remember how long (many 
months ) the sockets of my large molar teeth stood open, and 
even when they did heal up, the gums were full of morbid 
sensibility. When I last saw you, I had only about five 
front teeth remaining, and eight below. About 1818 they 
began to ache a little, and, as usual, to irritate and inflame 
my cheeks. The five upper ones began to spoil ; but I fought 
on with them until the winter of 1819, when the inflamma- 
tion, and the various sensations I have mentioned before as 
now suffering, increasing, and the teeth themselves aching, I 
had them pulled. The gums swelled and inflamed most 
dreadfully, the horrid sensations in the roof of my mouth in- 
creased, and my face was as bad as ever. In about a month 
the wounds healed, but the gums remained swelled and be- 
came a hard white gristle. After suffering for many months, 
I had the gums opened. They were so hard and thick, the 
dentist said they were like bone. The sockets were not the 
least absorbed; of course, rough, and in some parts exfo- 
liated. 

" The gun s were kept open near a month, and caustic ap- 
plied to excite absorption. In the course of this process the 
point of a tooth was discovered in one of the sockets, and ex- 
tracted. It was a full grown eye-tooth, which, for want of 
room, had never made its way down. I was easier as long as 
the gums were open; but just where I was, when they healed 
up and resumed their state. 

"Some months after this, my under jaw became affected; 
the teeth were not spoiled, but became so painful to the touch, 

16 



234 EFFECTS OF DISEASED TEETH AND GUMS. 

that I could bear nothing in my mouth to touch them. My 
lips became very tremulous, and my hands trembled so that 
I could neither feed nor dress myself. When warm in bed 
they ceased; but from the moment I rose and began to speak, 
or let the air into my mouth, I never ceased trembling, and 
the dry retchings (which you remember how tortured I 
used to be with) increased so as to bring on vomiting. I 
suffered in this way for eleven weeks, when, in despair, I 
had all my remaining teeth pulled. The tremblings and 
retchings quickly abated, and in a few weeks completely 
left me, and I have never had them since. My under gums, 
even before the teeth were pulled, were a hard gristle, and 
almost as white as the teeth. My gums have been often 
opened to give me relief, but as nothing will induce them 
to suppurate, I get no advantage, the wounding only in- 
creasing the hardness. 

" These gums seem to me to act as levers, pressing on the 
nerves and blood-vessels, and keeping up a constant irritation 
and inflammation in my mouth and face. 

" Under an idea that my complaint proceeded from neu- 
ralgia, I was advised to have the mental nerves divided at 
the chin, which did no good, and has created such hard tu- 
mors on these places, that I think their pressure on the side 
of the jaw is the cause of the twitching pain of my under 
lip, and the contraction of the muscles. 

" I would take it as a great favor if Mr. Koecker would 
say whether he thinks he could be of any use to me here, 
until I am able (which, alas ! I fear I am not,) to come to Lon- 
don ; or if he could give me any advice which I might desire 
to be done here ; and if he will be so very good as to men- 
tion what are the different kinds of diseases he has ever met 
with in the gums or alveolar processes, and his mode of treat- 
ment. There seems to be an idea here that if the sockets 



EFFECTS OF DISEASED TEETH AND GUMS. 235 

are not carious, there can be no disease there ; but I think 
Fox mentions otherwise. 

"My upper gums had not been touched for four years, 
until a week ago, when a part was opened that was very 
troublesome, and much swelled. The bone was full of points 
and inequalities, and rough; sounding gritty, like sand. 
There was a great deal of thick slime, like the white of 
egg, mixed with blood. Some nitrous acid was put upon 
the wound, to try to keep it open a little, but in vain. It is 
already covered with a new gum, and the old thick parts 
gaping open. I am sure if these old swelled gums could be 
got away, I should suffer less 

"I should think there is about the eighth of an inch of the 
socket remaining. The ridge of the under jaw is as sharp 
as a knife, and so painful to the touch, when I press it, that 
it makes my face, ears, and neck burn. My lips are painful, 
and are drawn in. I was advised to try false teeth, but they 
increased my sufferings ten-fold, which is very hard, as the 
clinching of my jaws adds much to my sufferings. My eyes 
are beginning to be much affected, which must plead my 
apology to Mr. Koecker for this sad scrawl, which I think 
you will need to help him to decipher. 

"There are various opinions about my complaint. One 
says it is a nervous complaint at the origin of the nerves, af- 
fecting thy extremities of these nerves; others say it is a 
nervous affection of the dental nerves and their ramifications 
on the face ; and others are of the opinion it is an affection 
of the covering of the bone. I am satisfied it is some disease 
of the antrum. Could it injure me to have the antrum opened 
to ease my mind? There is one place where I think there 
is part of a fang of a tooth, which I am certain was broken 
as the dentist burnt the tooth without letting me see it, per- 
haps that may torment me." 

Mr. Koecker gives no opinion upon this case; but the 



236 EFFECTS OF DISEASED TEETH AND GUMS. 

daly seems to me to have had. more discernment than her 
professional advisers. The disease was probably seated in 
the antrum, and very likely the fragment of fang was the ir- 
ritating cause. 

The following cases are reported by Dr. C. A. Harris : — 

Case 7. "In September, 1830, I was consulted by Mr. 
, at that time a resident of New York. Before I ex- 
amined his teeth, he informed me that his general health had 
been very bad for four or five years past, and that he had 
applied to some of the most eminent physicians of New 
York, Troy, and Albany, but had not obtained any perma- 
nent relief from his sufferings. 

" The character of the symptoms that prevailed at this 
time were very peculiar. His digestive organs were so 
much deranged, that he was obliged to observe the strictest 
regimen, and confine himself to the simplest kind of vegeta- 
ble food. Besides the dyspeptic affection with which he was 
troubled, he had severe paroxysms of headache and vomit- 
ing, that recurred at regular intervals of from four to five 
weeks. These were always preceded by numbness, which 
commenced in his tongue and extended thence throughout 
the whole system. This sensation continued usually for 
about ten hours, when it was succeeded by a violent pain in 
the head and partial vertigo, from which, in about ten hours, 
he was relieved by vomiting. The effects of these parox- 
ysms lasted about ten days, and the other symptoms had 
continued, without much mitigation, for three years. 

" On examining his mouth, I gave it as my opinion that 
the diseased state of his teeth was the cause of his affliction. 
This idea, though entirely novel to him, he was disposed to 
believe correct, and therefore readily consented to the 
treatment I prescribed. Many of his teeth were much 
decayed, and nearly all of them covered with tartar. The 
roots of some were denuded of the gums, the alveolar pro- 



EFFECTS OF DISEASED TEETH AND GUMS. 237 

cesses more or less absorbed, trie gums turgescent, fungoid, 
bleeding on the slightest touch, and of a dark red color. 
The secretions of the mouth were viscid, and their exhala- 
tions exceedingly offensive. 

" Such of his teeth as could not be perfectly restored were 
extracted, and as much tartar was taken away as could be 
conveniently removed at one time, and the rest at subse- 
quent sittings. His gums were freely scarified, and a tonic 
astringent and detergent wash directed to be used three or 
four times every day, Under this treatment the local affec- 
tion of the mouth rapidly disappeared, and in about four or 
five weeks his teeth and gums became perfectly healthy. 
His general health also began to improve, and in about two 
months it was perfectly restored, and has so continued." 

Dr. S , a distinguished surgeon and physician of 

Virginia, reports the two cases following : — 

Case 8. "Mrs. S , a lady of thirty or thirty-five 

years of age, with several children, in easy circumstances, 
rather delicate, and of sedentary habits, complained of de- 
rangement in the functions of the digestive organs, with much 
nervous disorder, and a painful sensation about the head, as 
if there were a pound weight on the top of it, with an occa- 
sional tightening of the scalp. This last sensation, she com- 
pared to that which might be expected from having the 
scalp forcibly drawn together on the vertex by the clawing 
of some animal with talons, as a hawk. Her friends, at first, 
thought but little of her complaints, and from their eccentri- 
city were inclined to believe them, for the most part, imagi- 
nary. The affection of the head, however, and the sensitive- 
ness of the nervous system, evidently increased, until they 
became so harassing and acute, that they deprived her of 
rest and made manifest inroads upon her healthful appear- 
ance. 

"Medical advice having been now obtained, a regular 



238 EFFECTS OF DISEASED TEETH AND GUMS. 

and carefully directed course of purgatives was prescribed, 
but with little or no advantage. The cathartics having been 
discontinued, the Eub. Ferri, Bark, Yalerian, Mineral Acids, 
Zinc, Assafoetida, &c, were next tried, to which were added 
frictions and tepid salt baths, but still without any material 
amendment. 

"She now began to have evident exacerbations of fever to- 
wards evening, which passed off with copious and debilita- 
ting sweats that much reduced her, and caused her counte- 
nance to assume a sickly aspect. She visited the watering 
places in Virginia, but though her strength was somewhat 
recruited, the distressing symptoms, with some slight modifi- 
cations, still continued. She was occasionally confined to the 
house, but generally was able to take some slight exercise in 
the open air. 

" This state of things had continued for eighteen months, 
when the attention of her physician was called to an abscess 
formed near the root of one of her incisor teeth. This 
brought about an inquiry into the general state of her teeth, 
of which the following is the result : 

"Mrs. S , at an early period had bad teeth, which, 

since her marriage, had been gradually growing worse. A 
few years before the time of which I speak, two of the incisors 
of the upper jaw were clipped off close to the sockets, and 
artificial teeth were inserted on the fangs. Much pain, irrita- 
tion, and swelling of the gums and lips followed the opera- 
tion, and similar symptoms occasionally occurred for a year 
or two afterwards, and were frequently attended with alve- 
olar abscesses. The remaining incisors of the upper jaw 
and several of the inferior and superior molar teeth were 
found to be in a dilapidated state. The alveolar processes of 
several of the inferior molars were partially destroyed, and 
one or two of their roots were turned to one side and clung 
to the alveoli by the remaining integuments. 



EFFECTS OF DISEASED TEETH AND GUMS. 239 

"The situation of the mouth rendered it quite probable 
that the ill health of the patient arose from the irritation pro- 
duced by the bad state of her teeth ; the more so, as her ner- 
vous system was exceedingly sensitive. She was persuaded 
to have the carious incisors and the worst of the molars re- 
moved, and, a short time after this was done, her health be- 
gan to improve. The affection of the head and scalp soon 
ceased, the nervous symptoms vanished, and she is now in 
good health, and has a set of teeth decidedly more ornamental 
than those given her by nature ever were. The speedy 
restoration of her health after the removal of her diseased 
teeth, justifies the conclusion that her bad health depended 
on the bad state in which these organs were found." 

The following case, related by the same gentleman, is par- 
ticularly worthy of attention as showing the terrible conse- 
quences which may result from ignorance of the effects 
which disease of the teeth, or even of a single tooth, is capa- 
ble of producing in subjects of certain constitutions : 

Case 9. "Miss "W , a maiden lady of about fifty years 

of age, in comfortable circumstances, and for the most part 
sedentary of habit, had suffered much from pain in the 
right cheek. For some time it was not considered of much 
moment, but, on its continuance, a physician was consulted. 

"He found but a single tooth, one of the second molars, in 
the superior maxillary of the affected side, and that was in 
a semi-decayed state. The gums above the teeth, and for 
half an inch on each side of it, were much swollen, and of a 
livid redness. The tumor seemed spongoid and puffy to the 
touch, but there was neither fluctuation nor abscess. The 
patient's health had not sensibly deteriorated. She said the 
tumor on the gums had existed for many weeks, but had not 
been attended with any remarkable pain until the occurrence 
of that of which she complained. She described it as being 
deep in the cheek, and generally dull, but now and then, for 



240 EFFECTS OF DISEASED TEETH AND GUMS. 

an instant, sharp and lancinating. She said the tooth for 
several years past, had been accustomed to ache occasionally, 
but that, notwithstanding its decayed state it was very use- 
ful, and she had therefore declined having it extracted. 

"The immediate extraction of the tooth was, however, 
thought advisable, and with her consent, it was effected. A 
week afterwards the spongy tumor of the gum continued, 
without any abatement of the pain in the cheek. The tumor 
was now laid open with a lancet. It contained no matter, 
but was filled with those shaggy or shreddy fungi which are 
often seen to occupy tumors or diseased bones. An abscess 
or some other affection of the antrum was suspected. A 
perforation was therefore made in its cavity, and about a 
table-spoonful of very dark brown matter discharged, which 
gave the silver spoon into which it was received a thin coat 
of the blackest pigment, and, on account of its offensive smell 
was almost insupportable. There was a difficulty in reach- 
ing the disease with remedies, and it was thought ad- 
visable to enlarge the communication with the antrum. 
The crown of a small trephine was accordingly applied to 
the alveolar portion of the superior maxillary, the soft parts 
having been first dissected up, and a corresponding portion 
of the bone was removed. The end of the little finger could 
now be introduced into the antrum, the inner surface of 
which, it was easy to perceive, had, at several points, been 
denuded of the pituitary membrane and of the periosteum. 

" The disease was now fairly exposed, and nothing could 
exceed the offensiveness of its fetor when not corrected by 
suitable dressings. The usual antiseptics and detergents 
were locally applied, while tonics and a generous diet were 
prescribed to sustain the patient's general health, and every 
effort was made to substitute a healthy purulent secretion 
for the ill-conditioned and offensive discharge from the an- 
trum, bat without any effect. 



EFFECTS OF DISEASED TEETH AND GUMS. 241 

"An irremediable necrosis seemed to have taken possession 
of the superior maxillary of the affected side, which soon be- 
gan to come away by piece-meal. In the meantime the soft 
parts about it were laid waste by the phagedenic character 
of the ulceration, and the eye of the same side became se- 
riously affected. The disease now progressed rapidly. The 
perforation of the antrum was made on the 11th of March, 
1821, and on the 26th of May following, the patient was 
found in a perfect state of apoplexy, the disease having pe- 
netrated the basis of the cranium and seized upon the brain 
itself. On the 30th of the same month she expired, and was 
thus released by death from the most horrible disease that can 
be conceived, but which has its origin in nothing more ex- 
traordinary than a neglected carious tooth." 

PHTHISIS PULMONALIS INDUCED BY DENTAL IEEITATION. 

Dr. M , an eminent practitioner of this State, reports 

the following extraordinary case : 

Case 10. "In the summer of 183-1, I was called to visit 
Mr. D. M , who had come into this neighborhood to ob- 
tain the benefit of the country air, having resided in Balti- 
more from his earliest youth. When I saw him he was in 
the last stage of phthisis pulmonalis. He gave me the fol- 
lowing history of his case : 

"About eight years previous he felt a soreness and tume- 
faction in his gum at the posterior part of his mouth, and as 
he had never cut the dentes sapientise, he thought the dis- 
quietude was occasioned by the progress of one of these teeth, 
and in consequence gave it no attention until the soreness 
and inflammation had extended themselves over the whole 
surface of his mouth and fauces. The tooth not having pro- 
truded through the gum, he consulted his family physician, 
who advised immediate extraction. 

"In conformity with this advice, he called on an eminent 



242 EFFECTS OF DISEASED TEETH AND GUMS. 

dentist of Baltimore, but the tooth not having presented 
itself and the cause of his suffering being doubted, the opera- 
tion was deferred. His sufferings, however, having become 
intolerable and the irritation having extended itself to the 
lungs, producing considerable uneasiness, he determined, if 
it were at all possible, to have the tboth removed. A few 
days after, he stated his determination to the dentist. The 
gum was freely split, and after considerable pain and diffi- 
culty, the tooth extracted. The inflammation in his mouth 
and fauces immediately subsided, his appetite returned, and 
his general health soon became as good as formerly. 

"About three years subsequent to this, his mouth and 
fauces, under similar circumstances, and from the same cause, 
became very sore and painful. The inflammation soon 
reached the lungs and established a confirmed phthisis pul- 
monalis. He died a few weeks after my first visit. 

The subject of this case was doubtless the victim of tuber- 
cular disease of the lungs. The tubercles were latent until 
the dental irritation was propagated to them, when inflam- 
mation and softening rapidly ensued. The teeth, though 
they did not, strictly speaking, cause the consumption, evi- 
dently precipitated it and perhaps anticipated the fatal deve- 
lopment by many years. The same physician, to whom we 
are indebted for the preceding case, has recorded another, in 
which the fatal result was more directly attributable to den- 
tal suffering. He says : 

Case 11. "My friend, Dr. L , of Frederick, Md., was 

called to visit a young gentleman who labored under violent 
pain of the face and inferior maxillary, with very great tume- 
faction of the gums. His sufferings were traced to the roots 
of one of his molar teeth, which had been broken in an at- 
tempt to extract it. His gums and the glands of his throat 
became so much enlarged, that it was impossible to remove 
the offending portion of the tooth. The inflammation, not- 



EFFECTS OF DISEASED TEETH AND GUMS. 243 

withstanding the skilful exertions of the physician, rapidly 
increased, high and intractable fever supervened, deglutition 
became totally obstructed, and, in a few days, he died." 

Case 12. A case very similar to the last, though more 
fortunate in its results, came within my knowledge lately. 
A dentist was applied to to extract a molar tooth, which he 
did. He told the patient that the tooth had come~out en- 
tire ; and dismissed him. Violent inflammation ensued, a large 
abscess formed, and the life of the man was brought into im- 
minent jeopardy. His physician called in a surgeon, and 
both being baffled, an eminent dentist was consulted. He 
suspected that a fragment of the root had been left, and after 
great difficulty, owing to the swelling of the parts, he suc- 
ceeded in extracting it, and saving the life of the patient. 

Dr. Fitch, in his "System of Dental Surgery," narrates a 
number of cases of constitutional disease, evidently caused 
by the protracted irritation incident to diseased conditions 
of the teeth and gums, from which I select the following : — 

Case 13. "In February, 1827, Dr. Samuel Jackson called 

and requested me to see Mrs. E , living in Tenth above 

Walnut Street, who, he said, was laboring under every symp- 
tom of confirmed phthisis pulmonalis, and also appeared to 
suffer greatly from a diseased state of her mouth. I accord- 
ingly called on Mrs. R . The following were her symp- 
toms. Great emaciation, hectic fever, almost constant 
cough, nearly a total loss of voice, articulation being ex- 
tremely difficult, the voice as if speaking through a trumpet. 
Dr. Jackson said that in the practice of seven years in the 
hospital, almshouse, and private practice, he had never seen 
a person recover from the symptoms under which Mrs. 
E, labored. 

"The following was the condition of Mrs. R 's mouth. 

About two years before she had the upper wisdom-tooth of 
the left side plugged, and the plug was pounded in by a 



244 EFFECTS OF DISEASED TEETH AND GUMS. 

mallet and punch. The fangs of the tooth converged toge- 
ther so as to form a fang of a conical shape. In hammering 
in the plug the socket was much injured. A chronic inflam- 
mation took place, which passed back over the palate, half 
arches, and some distance down the oesophagus, also over the 
glottis, epiglottis, and larynx. It then travelled forwards on 
the right side of the under jaw, and caused to inflame and 
slough away all the sockets and teeth of the lower jaw but 
one, which was the left dens sapientise. When I first saw 
Mrs. K the process of inflammation, sloughing, and gan- 
grene was at its height. Extensive exfoliations of the jaw 
were taking place. Dr. Jackson and myself concluded that 
the patient could not live more than four weeks. 

" Treatment. I at once removed all the teeth that were 
loose, and whose sockets were in a state of gangrene and ex- 
foliation. I likewise, as fast as possible, removed all the 
dead bone, and directed the patient to wash her mouth con- 
stantly with a strong infusion of powdered galls. In about 
eighteen days her mouth was perfectly well. The amendment 
of her general health was surprisingly rapid. In five weeks 
she was able to take long walks in the street, and in six 
months she was restored to perfect health. Nearly six years 
have passed away, and she still continues perfectly well." 

As a corollary to this case, Dr. Fitch very properly ob- 
serves : " I think we may safely infer, although diseased teeth 
do not, in every instance, excite general diseases of the system 
and of the lungs, yet, like an insidious enemy, they are ever 
ready to unite with or exasperate other causes, so as finally 
to undermine the powers of the system. I would earnestly 
solicit the attention of the medical faculty in general to a 
critical inquiry into the state of the teeth in all cases of pul- 
monary affection, and there is hardly a doubt that their in- 
quiries would result in the general conclusion that a diseased 
state of the teeth and gums do very frequently excite pul- 



EFFECTS OF DISEASED TEETH AND GUMS. 245 

monary affections, especially in persons predisposed to them, 
and always aggravate these complaints, let them be excited 
by whatever cause they may." 

Professor Chapman, of the University of Pennsylvania, in 
his lectures related the following case : — 

Case 14. " Some years since a lady came from a -distant 
part of the country to this city, in pursuit of medical aid, and 
placed herself under the care of Dr. Chapman. He found 
her laboring under every symptom of obstinate dyspepsia, by 
which her health and strength were greatly impaired. His 
correct and well known acumen in the pathology of disease 
immediately led him to inquire into the state of her gums and 
teeth. He found her gums in a high state of inflammation, 
and many of her teeth loose and diseased. By the direction 
of Dr. Chapman she applied to one of our most respectable 
dentists, and had her mouth and teeth placed in a healthy 
condition, and with the return of health in her teeth, gums, 
&c, every dyspeptic symptom left her, and she became quite 
well. 

" After some time had elapsed, and the lady's health 
seemed confirmed, she had a few artificial teeth placed in her 
mouth to supply some which she had lost, which either from 
not being well adapted and properly inserted in her mouth, 
or from some peculiarity in the lady's constitution, proved a 
source of irritation, and brought on a return of the distress- 
ing dyspeptic symptoms, which compelled her to dispense 
entirely with the artificial teeth, when her health was again 
completely restored." 

The celebrated Baglivi observes that " Persons whose teeth 
are in an unclean and viscid state, though daily washed 
have universally a weak stomach, bad digestion, and offensive 
breath, headache after meals, generally bad health and low 
spirits. If engaged in business or study they are irritable 
and impatient, and are often seized with dizziness. From 



246 EFFECTS. OF DISEASED TEETH AND GUMS. 

weakness of the stomach they are naturally somnolent, 
scarcely wakeful in the morning, and never satisfied with 
sleep." 

Hufeland enumerates sound teeth among the signs of long 
life. "For good digestion/' he says, "good teeth are ex- 
tremely necessary, and one, therefore, may consider them 
among the essential properties requisite for long life : and in 
two points of view : First, good and strong teeth are always 
a sign of a sound, strong constitution and good juices. Those 
who lose their teeth early, have in a certain measure, taken 
possession of the other world, with a part of their bodies. Se- 
condly, the teeth are a great help to digestion, and conse- 
quently, to restoration." 

Mr. Liston observes :* " From the presence of carious teeth, 
or decayed portions of teeth, many evils, both local and general, 
ensue, besides inflammation and abscess. They are frequent- 
ly the cause, and the sole cause, of violent and continued head- 
aches • of glandular swellings in the neck, terminating in, or 
combined with, abscess ; of enlargement and inflammation of 
the tonsils, either chronic or acute ; of ulcerations of the tongue 
and lips, often assuming a malignant action from continued 
irritation ; of painful feelings in the face, tic-douleureux, pains 
in the tongue, jaws, &c; of disordered stomach from affection 
of the nerves, or from imperfect mastication; of continued 
Constitutional irritation, which may give rise to serious dis- 
eases." 

Case 15. (Dr. Fitch.) "Mrs. S , aged about 38 years, 

was sent to me, by one of our most eminent physicians, with 
a request that I would examine her teeth, and perform such 
operations upon them as I judged proper, to render them 
and the gums healthy. The state of this lady's health was 
miserable; she was harassed by the most distressing symp- 

* Liston's Surgery. 



EFFECTS OF DISEASED TEETH AND GUMS. 247 

toms of dyspepsia. Her digestion was very imperfect, the 
stomach irritated, loss of appetite, and a most melancholy 
depression of spirits. When she first called it was necessary 
for her to repose herself for some time, before she could have 
her month examined. 

"Upon examining her teeth and gums, I found nearly all 
the former in a state of disease, and the latter were in a state 
of suppuration, much inflamed and swollen. A considera- 
ble deposit of tartar was formed around the necks of the 
teeth ; in several instances their fangs were denuded of the 
gum by the deposit of tartar, and, in fine, her mouth was in 
a general state of disease. I need not detail the several ope- 
rations by which her mouth and teeth were rendered healthy. 
Suffice it to say, that in about four weeks her mouth was 
perfectly well. The amendment of the general health after 
the first operations were performed on her teeth, was almost 
surprising, and would have been entirely so to any person 
not acquainted with the immense sympathy between the 
mouth, gums, &c, and the stomach. 

" Within five weeks after I saw her, every vestige of disease 
in her digestive organs left her, and she was apparently in 
perfect health." 

Case 16. Neuralgia from diseased teeth. — (Prof. Harris.) 
" The following is one of the many cases of tic-douleureux or 
neuralgia faciei, produced by disordered teeth, that have 
come under my own observation. 

"The subject of it was a lady about forty years, of sedentary 
habits, and naturally of rather a nervous temperament. For 
several years she had been afflicted at times with a most dis- 
tressing and painful affection of her face, which was pro- 
nounced by her physician to be tic-douleureux. The pain was 
sometimes so acute and lancinating that it almost deprived 
her of reason. It generally commenced near or a little anterior 
to the angle of the superior maxillary bone, thence it darted 



248 EFFECTS OF DISEASED TEETH AND GUMS. 

across the face to the alas of the nose, and then to the tem- 
ple; forehead, and angle of the eye, accompanied with frequent 
and sudden transitions from one side to the other, twitching 
and tremors of the muscles of the affected parts, and with a 
preternatural flow of saliva. Her face, and sometimes the 
whole of her head, were rendered so sore by these paroxysms, 
that the slightest touch would produce pain. 

" These paroxysms, although they were generally of short 
duration, frequently recurred as often as ten or fifteen times 
in twenty-four hours, and sometimes lasted ten, sixteen, and 
even twenty days, after which they would gradually subside, 
having subjected her during their continuance to the greatest 
misery, and leaving after their subsidence a dull, heavy pain 
in one or both jaws. A sensation similar to this was always 
(especially in the right side of the uper jaw) experienced 
several days before one of these attacks, which often enabled 
her physician to ward them off, and finally led to the detec- 
tion of their cause. These spasms were more severe, and oc- 
curred more frequently in cold, damp and wet than in warm 
and dry weather. 

"Bark, quinine, carb. ferri, stramonium, belladonna, and 
various other tonics and anti-spasmodics were prescribed, 
but without any apparent beneficial effect. Leeching, sina- 
pisms and epispastics were also of no avail. As a last resort, 
it was determined to divide the affected nerve, but before 
the operation the physician was induced by the pain in the 
jaws, always preceding these paroxysms, to examine the con- 
dition of the patient's teeth. The examination showed them 
to be in a very unhealthy state. The molares generally, and 
especially those on the right side, were involved in compli- 
cated caries. The gums were much tumefied and inflamed, 
and the gums sensitive. 

" Her teeth and gums, from the diseased condition in which 
they were found, were immediately supposed to have some 



EFFECTS OF DISEASED TEETH AND GUMS. 249 

agency in producing the affection of the face. A consulta- 
tion with me was therefore proposed, and I was requested to 
visit her. 

" On examining her teeth, I found that eleven were so much 
decayed as to render their restoration impracticable. It was 
therefore determined to remove them immediately, but it was 
not thought proper, owing to her extreme debility and the 
state of her nervous system, that more than two or three 
should be extracted at one time. 

"So great was her agitation at the mere thought of the 
operation, that notwithstanding the agony she suffered, she 
could not, on my first visit, be persuaded to have even a sin- 
gle tooth extracted, but requested me to call on the next day, 
when she promised she would submit to the removal of as 
many as she possibly could. 

"I accordingly called on the following day, and to the as- 
tonishment of her friends, she allowed all her jaw teeth that 
were carious, eleven in number, to be at once extracted. 
The operation at once revealed the cause of her disease. 
The roots of three of these teeth were very much enlarged 
by bony depositions. One of the fangs, was at its extremity, 
about the size of a pea. Those of the other two were not 
quite so large, but a disposition to exostosis was manifested 
by all. "With the removal of these teeth, all symptoms of 
pain entirely vanished, nor have they, to my knowledge, re- 
turned since." 

Case 17. Death caused by the extraction of a tooth. — ( Jour- 
dain.) "A citizen having submitted to the extraction of a 
tooth, the gums became gangrenous; the gangrene reached 
the brain and caused death. 1 ' The same author reports a 
case of 

Case 18. " Convulsions and death caused by the shortening of 
a tooth longer than the others. A nun of Padua having had a 
17 



250 EFFECTS OF DISEASED TEETH AND GUMS. 

tooth, shortened in order to get rid of the deformity, died im- 
mediately in an epileptic convulsion. A small fragment of 
nerve was discovered in the section of the tooth." 

This case and others which fortunately have not terminated 
so seriously, should be a warning to all operators upon the 
teeth, not to inflict sudden and violent pangs. Experience 
shows us that a great amount of pain can be endured, if slowly 
and gradually inflicted, while instinct teaches us all to dread 
sudden pangs, even of more moderate intensity. Even in 
extracting a tooth, it is better to operate gradually rather 
than to wrench it out with a sudden and violent effort. If 
pain be gradually inflicted, the nervous system, conscious of 
the coming trial, summons up all its powers of endurance ; 
but when taken by surprise, the shock is severely felt, and 
the consequences may even be fatal, as in the case just quoted. 

Pain is a great evil. It should never be inflicted unneces- 
sarily, and when necessity occurs, the inflictor should use all 
possible means to render the suffering as tolerable as possi- 
ble. Moreover, there is great difference in individuals as to 
the tolerance of pain ; even as to the perception of it. Many 
persons will suffer terribly from operations which would not 
cause serious pain to others. The same persons will suffer 
much more at one time than another. All these considera- 
tions are well worthy the attention of the dentist. 

Yery severe headache of the neuralgic kind is frequently 
caused by diseases of the teeth and by the irritation produced 
by the presence of dead roots in the jaw. In illustration of 
this, I will quote a few from many cases : 

Case 19. "Inveterate headache cured by the extraction of 
many roots of carious teeth.— (Fabricus Hildanus.) A lady 
was afflicted with a very severe continued pain in the left 
side of her head. The violence of the pain was chiefly ex- 
perienced in cold damp weather. By the advice of her phy- 



EFFECTS OF DISEASED TEETH AND GUMS. 251 

sicians, she had tried a great many remedies, internal and 
external, but without success. Finally, I was called to see 
her. I carefully examined all the causes of her malady. I 
learned from her that for six months she was afflicted with 
ah agonizing pain in the teeth of the left jaw. After this, 
the pain somewhat abated, but left a similar one in the cor- 
responding side of the head. I conjectured from that the 
headache was caused by the roots of dead teeth. Upon ex- 
amining the upper jaw, I found four carious teeth whose 
roots were deeply planted. I advised her to have them ex- 
tracted, to which she cheerfully consented. I then purged 
her freely, and applied cups to her neck and shoulders, and 
an aposeme to be taken during four days in the morning. 
On the fifth, while fasting, I extirpated the roots." After 
other treatment of a kind then in vogue, but of no utility, 
the lady recovered. 

Case 20. Headache dependent upon the teeth, — (M. Petit.) 
"The late Princess of Conde' recommended to her physicians 
one of her protege's, to be cured of a headache of five years' 
duration. She had been bled twenty times, and finally Mr. 
Petit was requested to bleed her in the throat. This surgeon 
having examined the patient, was led from her complaint of 
a pain and weight in the lower jaw, to look into her mouth. 
He found some irregularity in the teeth, and upon close in- 
spection ascertained that the patient had an unnatural num- 
ber of them, there being eighteen in the lower jaw. The se- 
cond molar on each side appearing to be most crowded, he 
took them out, and in twenty -four hours the lady was cured 
of a headache of five years' continuance." 

Case 21. Ophthalmia and loss of an eye by abscess upon the 
teeth. — (Fab. Hil.) "A lady of Cologne was for a long time 
tormented with inflammation upon the last molar of the left 
side, which was carious. By the advice of physicians, she 
was frequently purged, and cupped between the shoulders, 



252 EFFECTS OF DISEASED TEETH AND GUMS. 

but as she ref used to have the tooth extracted, the continued 
irritation of the gums occasioned inflammation of the eye on 
the same side, which finally destroyed the sight." 

Case 22. Ear-ache cured by extracting a tooth. — (Jourdain.) 
"A lady had long suffered with severe pain in the right ear. 
All the ordinary remedies were used without effect. At 
length she was asked if she had any carious teeth. She re- 
plied that she had not: that all her teeth were good, and 
never gave her any inconvenience. Nevertheless, her mouth 
was carefully examined. At first sight all seemed right, but 
a close inspection showed external caries of the dens sapien- 
tise. As the pain of the ear extended to the angle of the jaw, 
and even a little along its base, I persuaded the lady to per- 
mit me to extract this tooth, which I suspected to be the 
real cause of the mischief. Three days afterwards, the lady 
was perfectly and permanently relieved." 

A similar case is reported by Mr. Koecker. 

Dr. Darwin relates several cases of serious disorder pro- 
duced in adjacent parts and in the general system by diseased 
teeth. The following are very remarkable : 

Case 23. "Mrs. , about thirty years of age, was seized 

with great pain about the middle of the right parietal bone 
which had continued a whole day before I saw her, and was 
so violent as to threaten convulsions. Not being able to de- 
tect a decaying tooth or a tender one, by examination with my 
eye or by striking them with a teaspoon, and fearing bad con- 
sequences from her tendency to convulsions, I advised her 
to extract the last tooth of the under jaw on the affected side, 
which was done without any good effect. She was then di- 
rected to lose blood and Jo take a brisk cathartic, and after 
that had operated, about sixty drops of laudanum were given 
her with large doses of bark, by which the pain was removed. 

"In about a fortnight she took a cathartic by ill advice, 



EFFECTS OF DISEASED TEETH AND GUMS. 253 

and the pain returned with greater violence in the same 
place, and before I could arrive, she suffered a paralytic 
stroke, which affected her limbs and her face on one side, and 
relieved the pain of her head. 

"About a year afterwards I was again called to see her on 
account of a pain as violent as before, exactly on the same 
part of the other parietal bone. On examining the mouth, 
I found the second molaris of the under jaw, on the side be- 
fore affected, was now decayed, and concluded that this tooth 
had occasioned the stroke of the palsy, by the pain and con- 
sequent irritation it had caused. On this account I earnestly 
entreated her to allow the sound molaris of the same jaw, 
opposite to the decayed one, to be extracted ; which was forth- 
with done, and the pain of her head immediately ceased." 

Case 24. (Darwin.) Since the above was first published, 
I have seen two cases which were very similar, and seemed 
much to confirm the above theory of sympathetic hemi crania, 
being, perhaps, always owing to the sympathy of the mem- 
branes about the cranium with those about diseased teeth. 

"Lord M. and Mr. B., of Edinburgh, both of them about 
the middle of life, were afflicted with violent hemicrania for 
about two years ; in the beginning of which time, they both 
assured me that their teeth were perfectly sound, but on in- 
specting their mouths I found all the molars were now so de- 
cayed as to have lost their crowns. After having suffered 
pain for sixteen or eighteen months, almost incessantly, in 
different parts of their heads, they had each a hemiplegia, 
from which they gradually recovered as much as paralytic 
affections generally do recover. All the stumps of their 
teeth which were useless were directed to be extracted, as 
the swallowing so much putrid matter from decaying bones, 
seemed to injure their digestion." 

Sir Henry Halford, in a paper on tic-douleureux, read be- 



254 EFFECTS OF DISEASED TEETH AND GUMS. 

fore the College of Physicians, related the following cases 
which came under his own observation : — 

Case 25. "A lady, forty years of age, suffered under the 
violent form of tic-douleureux, at Brighton, notwithstanding 
the careful attention and skill of a very judicious physician 
there. On returning to town, it was observed that the rend- 
ing spasms, by which the disease is marked, were frequently 
preceded by an uneasiness in one particular tooth, which ex- 
hibited, however, no signs of unsoundness ; but the constancy 
of this symptom was enough to justify the extraction of the 
tooth in this instance ; and on its being drawn, a large exos- 
tosis was observed at the root of the tooth, and the lady never 
suffered more than very slight attacks, and these very seldom, 
afterwards." 

Case 26. (Sir Henry Halford.) "The late Earl of C. un- 
derwent martyrdom by this disease, and excited the warmest 
sympathy of his friends by the agonies he sustained for many 
years. He submitted to the operation for the division of 
several branches of the fifth pair of nerves repeatedly, by Sir 
Everard Home and Mr. Charles Bell, without obtaining more 
than temporary relief. At length he was seized with apo- 
plexy, and lay insensible for some days, and in great peril, 
from the attack, but finally recovered. After the apoplexy 
the paroxysms of tic-douleureux became less frequent and 
less severe, and were administered to satisfactorily by an in- 
genious physician, who wrote his inaugural exercise on the 
disease. For the last year or two of his life his lordship 
ceased to suffer from the tic-douleureux, and died at an ad- 
vanced age, without any marked malady. While I attended 
him he underwent repeated exfoliations of the alveolar process of 
the teeth, which I thought occasioned his torment." 

Doubtless, the exfoliations being completed, and the disease 
of those parts removed, the irritation ceased, and the patient 



EFFECTS OF DISEASED TEETH AND GUMS. 255 

recovered. It is melancholy to think of the protracted suf- 
fering which rendered the life of this unfortunate nobleman 
wretched and comparatively useless, and which might pro- 
bably have been cured with little difficulty, if such men as 
Sir Everard Home and Mr. Ghas. Bell had been aware of the 
sympathetic disorder which may be, and often is, produced 
by diseased teeth. These eminent gentlemen not only did 
no good, but they inflicted great additional pain on their un- 
happy patient; but, doubtless, he would have fared little bet- 
ter in other hands, for the profession, while searching with 
powerful microscopes for causes of disease, entirely overlook 
the teeth, though reason and experience, the demonstrations 
of the anatomist, and the voices of the most discerning of the 
masters in medicine, are continually pointing them to the 
important sympathies of these organs. 

From its relation to the teeth of the upper jaw, the fangs 
of which frequently perforate its floor, the antrum is often 
the seat of disease of a serious and sometimes fatal character, 
resulting from irritation produced by diseased condition of 
these highly sensitive organs. Indeed, the teeth are directly 
or indirectly concerned in most of the diseases of the antrum. 
Boyer, Deschamps, Harris, and most others who have writ- 
ten upon this subject, give united testimony to this fact. 

Dr. Harris, in the second edition of his valuable work on 
Dental Surgery, record several cases in evidence of the fa- 
cility with which diseased teeth may propagate disorder 
to the antrum, and the formidable diseases which may result 
therefrom. I select the following : — 

Case 27. (Dr. Harris.) "Mrs. L., at twenty-seven or 
twenty-eight years, of a scrofulous habit, had been at times 
affected, for more than two years, with a deep-seated pain in 
the right side of her face, midway between the orbit and the 
alveolar ridge, and on closing the left nostril, and making 
a violent expiration through the right, discharged a slightly, 



256 EFFECTS OF DISEASED TEETH AND GUMS. 

jet perceptibly fetid mucous matter, which occasionally ex- 
coriated the mucous membrane lining this cavity of the nose. 
The pain, from the fact that it was most severe in cold and 
damp weather, was thought to be rheumatic. General and 
local bleeding, fomentations, mustard plasters, purgatives, 
anodynes, tonics, and many other remedies, had been em- 
ployed in vain. 

"A severe paroxysm of toothache, about this time, more 
than two years since she first felt the deep-seated pain in her 
cheek, induced her to apply to me. 

" On examining her mouth, the crowns of the second mo- 
lar, dens sapientiae, and first bicuspis, of the affected side, 
were found to be destroyed by caries ; the gums, covering 
the sockets of their roots, were inflamed and very sensitive. 
It was the roots of the wisdom or third molar tooth that 
ached. Extraction being the only remedy that held out the 
least prospect of relief, I at once proposed the operation, and, 
at the same time, urged upon her the importance of having 
the roots of the second molar and first bicuspid removed. A 
great deal of persuasion was necessary to obtain her consent, 
she being of an exceedingly nervous and timid disposition ; 
but, having made up her mind to submit, she determined to 
have the operation performed immediately. She had no 
cause to regret it; for not only was she freed from the an- 
noyance which the roots had occasioned to her tongue, gums, 
&c, but the operation was also followed by a speedy subsi- 
dence of the pain in the cheek, and a cessation of the fetid 
discharge from the nose." 

Case 28. (Dr. Harris.) "In December, 1841, I was con- 
sulted by Mr. S. M. J , twenty -three years of age. He 

had been affected for several months with a dull heavy pain, 
which, as he said, seemed to be seated deep in his right 
cheek; and, as in the case last described, a fetid mucous mat- 



EFFECTS OF DISEASED TEETH AND GUMS. 257 

ter was discharged from the nostril of the affected side, on 
making a violent expiration, though it, with the other nasal 
cavity, closed. His teeth, to all appearance, were perfectly 
sound; but his gums, around the first and second bicuspides 
and first molar, were inflamed, spongy, and slightly ulce- 
rated between their edges and the necks of the teeth, from 
which they had separated, to the edge of the alveoli. This 
condition he attributed to a blow which he had received by 
a fall, upon these teeth, about two years before. It was im- 
mediately followed by pain, inflammation, and, in about two 
months, the exfoliation of several small portions of the alve- 
olar processes, which came out through the gum. These 
were the only unpleasant effects which he experienced at 
the time, but afterwards there was always a slight soreness in 
the teeth that had received the injury. This gradually ex- 
tended higher and higher into the substance of the jaw, 
until about four months previously to his calling upon me, 
when its place seemed to be taken by the kind of pain first 
described, and soon after, the fetid discharge from the nostril 
was discovered." 

" That the deep seated pain in the right superior maxillary 
was occasioned by inflammation of the mucous membrane 
which lined the sinus, I could not doubt; and that this had 
resulted from the alveolar irritation caused by the violence 
that had been inflicted upon the bicuspides and first molaris, 
to me, was equally evident. I therefore proposed the ex- 
traction of the teeth, to which he consented. Three weeks 
afterwards the pain in his jaw had entirely disappeared. 

Case 29. (Dr. Shepherd.) Neuralgia vs. Toothache. — "Neu- 
ralgia has become a very fashionable disease now-a-days, 
and many persons suffer long and severely, and ransack the 
whole materia medica in search of remedies ; and finally an 
examination of the teeth is thought of, the very first thing 



258 EFFECTS OF DISEASED TEETH AND GUMS. 

that should have been done. In nine cases out of ten of sup- 
posed neuralgia, the extraction of some badly-decayed tooth, 
which the suffering individual knows ought to have been out 
more than a year ago, perhaps, would cause a subsidence of 
all symptoms of neuralgia. 

" As a prominent example of the above, I am induced to 
report the following case: — Miss C. "W., a resident of this 
town, of delicate constitution, was attacked with severe pain 
in the right side of the head, neck and shoulder, about twelve 
months ago; and from the' severity of the pain, and other 
circumstances attending it, she came to the conclusion that 
it was neuralgia ; and by concurrence with her medical advi- 
ser, her opinion was confirmed. She used, therefore, all pos- 
sible remedies for that disease without success. In the mean- 
time her attacks were growing more frequent and more severe ; 
and for the last two or three months, they occurred daily at 
precisely five o'clock in the afternoon, and continued with the 
most intense severity until midnight ; when the pain would be- 
gin gradually to subside, growing less and less until she was 
perfectly easy. These daily attacks came on with such per- 
fect regularity, that to use her own words, 'five o'clock was 
a terror to her before it came.' At this stage of the disease 
she was in Baltimore, whether in search of medical advice or 
not, I do not know; but while there she consulted Dr. B., an 
eminent physician of that city ; and he advised her to have her 
teeth examined, intimating that they might be involved; he 
gave her, at the same time, a prescription for neuralgia, to 
be used in case the teeth were not at fault. With this advice 
she returned home, and sent for me, and related to me sub- 
stantially what I have stated above. I examined her teeth, 
and found the inferior wisdom-tooth of the right side, decayed 
to the nerve, and I gave it as my opinion that all her ' neu- 
ralgia' originated there; I therefore advised its immediate 
extraction, to which she assented. The first day after the 



EFFECTS OF DISEASED TEETH AND GUMS. 259 

tooth was extracted she had very little pain, the next still 
less, and the third none at all. 

"Thus a perfect cure was effected, of what, perhaps, nine- 
teen out of twenty of our very best physicians would have 
pronounced neuralgia, without once thinking of the teeth, 
by the simple extraction of a bad tooth. 

"I do not offer the above as a case of rare occurrence; I 
have often met with such in the course of my dental practice, 
as doubtless dentists in general have; and I cannot account 
for the fact, that physicians so generally prescribe for neu- 
ralgia, without once thinking of the teeth, when there is so 
striking a similarity to true neuralgia, in many cases of tooth- 
ache. In the case above, there were some striking peculia- 
rities, which would have been, perhaps, sufficient to screen 
the most vigilant from the charge of superficiality in the ex- 
amination of his patients, though he might have forgotten 
the teeth. The duration, the regular increase of pain, the 
extent to which the system was affected, and when the at- 
tacks became daily, the perfect uniformity as to the time of 
commencement, together with the nervous temperament of 
the subject, were all circumstances well calculated to mislead 
the judgment ; and yet this proved to be a case of toothache, 
a fact which might have been proved just as easily in its very 
commencement, if an examination of the teeth had been once 
thought of as a matter of any consequence. 

The cases above-mentioned, are but a few of an unlimited 
number that might be collected, showing the importance of 
the teeth, in their healthy and unhealthy conditions, to the 
well-being of the whole economy. Surely those here pre- 
sented will be sufficient to arouse the physician to the ne- 
cessity of regarding the agency of these organs in the pro- 
duction and continuance of diseases, and to impress the den- 
tist with the importance of pursuing his vocation, not as a 
mere mechanical craft to be exercised upon isolated excres- 



260 EFFECTS OF DISEASED TEETH AND GUMS. 

cences of the body, but as a part of curative science, em- 
bracing in its relations, the knowledge of diseased life as 
manifested by many organs, or by them all. The general 
surgeon must be more than a mere cutter of flesh or setter 
of bones; the obstetrician more than a man midwife; and 
the dentist is unworthy of the confidence or respect of the 
community who is not well informed upon the nature and 
history of disease, and the part which the organs upon which 
he operates perform in its causation, or modification. 

It is strange that physicians have paid so little attention 
to this subject. It would be less so, if so many of the ablest 
writers among them had not so earnestly and repeatedly 
proclaimed the importance of giving to the teeth their due 
consideration in the diagnosis of disease. But when Hunter, 
Eush, Darwin, Harford, Chapman, and many such men, have 
taken special pains to direct the attention of the profession 
to the subject, it is unaccountable that their voices have been 
almost totally unheeded. 

Unfortunately, it has now become the fashion to study 
-pathology in the corpse-house, rather than by the bed-side ; 
to make microscopical inquisitions of disease upon the dead, 
rather than to observe its phenomena in the living. From 
the very necessity of the case this necrological research falls 
into the hands of the young and inexperienced, and these be- 
come writers and teachers before they have been to the only 
sure school of medicine, the chamber of the sick. As the 
teeth may be seen by the naked eye, they are not likely to 
be considered of much importance. Had they been discerni- 
ble only by the microscope, they doubtless would have re- 
ceived due consideration. It is said that the celebrated Pen- 
nant, by use of the microscope, lost the use of his eyes. I 
fear that this is too commonly the fate of his successors. 

I fully coincide with Dr. Fitch, who well remarks : " We 
are not to contemn the diseases of the teeth because they 



EFFECTS OF DISEASED TEETH AND GUMS. 261 

seem insignificant. Many persons are formed of a fibre so 
fragile, as to be broken by the slightest shock ; of a stamina 
so delicate, as to be affected by the slightest impression. 
Disease in its steps at first is, as it were, soft and hesitating, 
weak in its powers, and slow in its progress. But every 
instance of indulgence, and each succeeding advantage 
gained, confirms its step, increases its powers, and hastens 
its progress, and what but a moment ago seemed a thing too 
insignificant to mention, now rises a monster that derides 
human effort, and whose sting is the arrow of death. 

"Almost inappreciable are the beginnings of many fatal 
diseases ; and could the grave reveal its secrets, I have not a 
doubt, when I consider the number of diseases produced by 
diseased teeth, that it would be found that thousands are 
there, in whom the first fatal impulse was given by a diseased 
state of these organs : and could I raise my voice so as to be 
heard by every medical man in America, I would say to 
them, attend to your patients' teeth, and if they are diseased, 
direct such remedies as shall restore them to health; and if 
in health, such means as will keep them so." 



CHAPTEE XT, 

WOUNDS OF THE MOUTH AND FACE. 

The face, with all the organs which enter into its struc- 
ture, is exposed to the several forms of injury which are 
known by the common name of wound. 

Surrounded as the human body is by a great number of 
substances denser and more resistant than itself, it is liable to 
have its tissues separated, penetrated, torn, violently com- 
pressed, and broken asunder. Consisting, also, of a number 
of elements constituting organized parts and held in union 
by the mysterious force of vitality, it is also liable to have 
this union dissolved by the action of forces more powerful 
than life, and to be chemically disintegrated. 

As the face, from the necessity of the case, must be unco- 
vered, and as from its position it is most liable to be injured 
by falls or reached by malicious blows, it is more frequently 
wounded than any other part of the body; and owing to the 
deformity which attends scarring of the countenance as well 
as the importance of the organs connected with it, facial 
wounds require more nicety in their management than any 
others. 

The mouth is very frequently involved in these injuries, 
and the teeth are often displaced or fractured by them. The 
manipulations required for the reparation of these injuries 
require a dexterity only to be acquired by daily observation 
of the teeth in their natural positions and the habit of hand- 
ling and operating upon them. The dentist, if believed skil- 



WOUNDS OF THE MOUTH AND FACE. 263 

ful, is therefore often called upon, even by the general sur- 
geon, to aid in the management of such cases. 

In medical language, a wound is a recent lesion or inter- 
ruption of the continuity of parts from an external cause; 
but the term is made to include all hurts received from agents 
acting mechanically or chemically upon the surface of the 
body. 

Wounds differ materially from one another, in kind, extent, 
position and character of the parts wounded. 

When the parts are merely divided by a clean, sharp instru- 
ment, with as little injury to the separated tissues as possible, 
the wound is called a Simple Incision — {simple incised wound) 

If the parts be rudely torn asunder, the injury is called a 
Laceration — [lacerated vjound.) If the parts be violently and 
suddenly compressed, so as to rupture some of the small ves- 
sels and break or otherwise injure the muscular fibre, skin, &c, 
the injury is called a Contusion or Bruise — (contused wound.) 
If a pointed instrument be forced into the body, penetrating 
tissues, it causes a Puncture — ('punctured wound) If a bone 
be broken, the wound is called a Fracture. Injuries from 
bodies propelled by gunpowder are called Gun-shot wounds, 
and by fire, Burns. To these may be added, Poisoned wounds, 
or those in which a slight puncture or trivial laceration be- 
comes the means of introducing venomous matter into the 
system ; such wounds are inflicted by certain insects, serpents 
and rabid animals. 

Simple Incised wounds are, per se, the least serious of all in- 
juries, though from the flow of blood which attends them, 
they are generally the most alarming. 

In these cases the parts are simply separated, of course not 
without injury at the immediate line of division, but with- 
out any which suspends the vital action of the separated 
surfaces, or breaks up their relation so as to render re-adap- 
tation difficult. 



264 WOUNDS OF THE MOUTH AND FACE. 

Of course these wounds may be of the most serious nature, 
or immediately fatal, if large vessels be divided or vital func- 
tions interrupted by them. In these cases, the danger is not 
from the nature of the wound, but from the accident of its 
seat. 

Commonly the most alarming and most dangerous com- 
plication of incised wounds, is the bleeding or hemorrhage 
which attends them. This will be greater or less, according 
to the size and character of blood vessels divided, the form 
of the incision and the vascular activity, &c, of the patient. 

A wound of this character may be attended by venous or 
arterial hemorrhage. 

A slight incision will commonly be attended by a gush of 
dark-colored blood from the superficial veins. This flows 
freely for some minutes, but if the wounded part be not effi- 
ciently bathed, and especially if it be bound up, the hemor- 
rhage soon ceases, and does not again return. 

Sometimes the gush is so considerable as to cause the pa- 
tient to faint, or, in medical language, to induce syncope.* 
In this condition the patient has temporarily lost his con- 
sciousness, his skin has become cold, and his pulse ceased to 
be perceptible. 

This state, though apparently very dangerous, is by no 
means so, unless the patient has previously been much ex- 
hausted. On the contrary, it is salutary; for it checks the 
hemorrhage and affords time for the permanent closure of 
the wound in the way to be described presently. 

As the syncope depends upon the want of circulation 
through the brain, the patient should be placed in a recum- 
bent position with his head low. If fainting be feared in 
any case, this is the best position and the best means to pre- 
vent it. 

* Syncope, Ivyvflnxu — I fall down. 



WOUNDS OF THE MOUTH AND FACE. 265 

The arrest of venous hemorrhage depends upon the sin- 
gular and most important quality possessed by the blood to 
solidify or coagulate when exposed to the air. Without 
such a provision, the slightest wounds would be very trouble- 
some, and often fatal. 

As soon as a coagulum forms about the orifice of the 
wounded vessel, the bleeding ceases, and the current of blood 
finding no longer an artificial egress, pursues its natural 
course. 

It is evident that if the flow of blood be very great, or if the 
wound be very large, the coagulum will be longer in forming 
a sufficient barrier to the hemorrhage. For the blood must 
be at rest before it can coagulate, and the amount which, 
under these circumstances, will be arrested by the edges of 
the wound, etc., and detained until coagulation, will bear but 
a small proportion to the current, and will be constantly 
washed away by it. 

It is in such cases that fainting is sure to occur, and by this 
means the flow being stopped, the blood at the moment filling 
the wound is arrested and coagulates before the action of 
the heart is recovered. 

Sometimes, however, it happens that small veins will bleed 
obstinately and profusely ; owing to the peculiar irritation of 
the wounded part or the indisposition of the blood to coagu- 
late. 

It is evident that compression of the lips of a wounded 
vessel so as to obstruct its channel, is the readiest way to stop 
the hemorrhage, and that as the flow of blood in the veins 
is towards the heart, the pressure should, when these vessels 
are wounded, be especially upon the distal extremity of 
the wound. Inasmuch, however, as the veins anastomose* 
freely, pressure must be exerted upon both sides of the wound. 

♦ Anastomose — communicate by a number of mouths — from Av*, and 
Ixviiu. — a mouth. 

18 



266 WOUNDS OF THE MOUTH AND FACE. 

As soon as the flow of blood through the vessel is arrested, 
the blood begins to coagulate at the point where it is impeded, 
and in a little while a plug of coagulum effectually stops 
each end of the divided vein. 

It is never necessary to tie a vein, unless it be of the largest 
size, and the operation is always very dangerous. Arteries 
may be tied with impunity ; but the veins, when thus treated, 
are very apt to develop an inflammation of their lining mem- 
brane (phlebitis*) which is rapidly propagated to the heart, 
and is generally fatal. 

Styptics, f of many kinds, have been employed more or less 
for ages, for the stay of hemorrhage. 

These are astringent substances which corrugate the animal 
fibre, thus contracting the orifice of the wound ; or articles of 
a porous or loose texture, which arrest a considerable quan- 
tity of blood, and thus form a clot. 

Lunar caustic, alum, the mineral acids, cold water, &c, are 
of the first class ; agaric, sponge, spider's web, fur, &c, of the 
latter. 

These articles are only useful where small superficial ves- 
sels are concerned. 

Arterial is far more serious than venous hemorrhage. The 
arteries circulate more blood, and with more rapidity. The 
blood from an artery is red, that from a vein purple and 
nearly black : the blood from a vein flows steadily ; from an 
artery it flows by leaps or jerks (per saltum.) These cha- 
racteristics will serve to distinguish the nature of the vessel 
injured. 

The rule, however, is not without exceptions. If a vein lie 
directly over an artery, the impulse of the latter may be so 
sensibly communicated to the former as to cause the blood 
to flow per saltum. Again, in one instance the author found 
the venous blood of a plethoric patient to be as red as ar- 

* Phlebitis — from qltyj, a vein. f Styptic, from 2Tt/pe/v, to constringe. 



WOUNDS OF THE MOUTH AND FACE. 267 

terial, when issuing from the orifice. This, however, is 
very rare. 

The loss from them is therefore much greater than from 
veins. Moreover, the arteries contract and expand, and 
force their blo'od, by this process, through their canals in jets 
or gushes. Hence it is almost impossible for a cbagulum to 
form of sufficient size to resist the force of the propulsion. An 
artery, unless of very small size, if once divided by a clear 
incision, will continue to bleed until the patient succumbs 
from exhaustion, unless artificial aid be afforded. 

The means of arresting arterial hemorrhage are, compres- 
sion, ligature, laceration and the actual cautery. 

Compression may be exerted either upon the trunk of the 
vessel at a spot nearer the heart than the wound, and where 
its superficial position or relation to a bone renders pressure 
more easy and complete, or upon the lips of the divided vessel. 

Pressure upon the trunk of the vessel can afford but tem- 
porary relief, as the current of blood will soon find its way 
through anastomosing branches into the vessel beyond the 
impeded point ; upon the lips of the wound, unless very much 
favored by position, it can rarely be perfect, as the arteries 
for the most part lie deep, and the means of compression 
must be applied at the bottom of the wound. 

The ligature is by far the most important of the means 
used for arresting hemorrhage, and the discovery of its 
aclaptedness is the greatest advantage of modern over ancient 
surgery. 

The ancients supposed that the arteries contained a mys- 
terious something, which they called the animal spirits, and, 
to prevent the egress of this, they resorted to the actual cau- 
tery; thus adding a most painful and dangerous burn to a 
wound often large and sufficiently serious. 

An artery is composed of three coats, viz. ; the outer or 
fibrous, the middle or muscular, and the inner or serous. 



268 WOUNDS OF THE MOUTH AND FACE. 

When a ligature is tied firmly around the vessel, the outer 
coat being firm and strong, remains unbroken : the middle 
and the inner or serous coat, are always lacerated. 

The effect of the ligature then is : 1st. To rupture the 
middle and internal coats of the artery. 2d. -To bring the 
lacerated parts into close contact. 3d. To produce adhe- 
sive inflammation by the exudation of coagulated lymph. 
4th. To cause the formation of a coagulum in the obstructed 
vessel; and 5th, To cause ulceration of the outer coat, by 
which the ligature is liberated and the wound suffered to 
unite. 

It appears then that the final closure of the vessel is the 
result of a most wise and benevolent provision of the Creator, 
which enables us, through the structure and vital properties 
of the arteries, to procure their obliteration at such point as 
we may select. 

This provision would, however, be entirely nugatory un- 
less some means were provided by which parts thus de- 
prived of circulation should receive it through other channels. 
But this means is provided in the facility with which, under 
these circumstances, the anastomosing branches are enlarged. 
Through these rapidly expanding canals the current of blood 
presses towards its destination, and in a few hours the in- 
convenience resulting from the complete obstruction of such 
trunks, even as the carotid and external iliac, is permanently 
remedied. 

In placing the ligature, which should be of hard-twisted 
silk, around the artery, great care should be had not to en- 
close in it the nerve or vein which commonly attend the for- 
mer. Serious and even fatal consequences would follow 
such a blunder as this. When the external coats of the 
vessel are so soft as to give way before the ligature, a little 
of the surrounding cellular tissue or muscular fibre may be 
enclosed within the thread. 



WOUNDS OF THE MOUTH AND FACE. 269 

The method to be pursued in reaching each particular 
artery will be found in the works on general surgery. It 
is not within the design of the present work to describe them. 

We have mentioned laceration as one of the means of ar- 
resting hemorrhages. 

"When an artery is torn, the internal coat is, of course, 
brought into the condition produced by the ligature, except 
that the opposing surfaces are not pressed together. It 
generally happens, however, that the shock of this kind of 
injury interrupts the contraction and expansion of the ves- 
sel, and a coagulum is thus permitted to form. This mode 
of operation is only proper when we have to deal with small 
vessels. Their bleeding may generally be arrested by seizing 
them with the forceps and twisting them so as to rupture 
their internal coats. 

The actual cautery* is a terrible means, which should only 
be used under peculiar circumstances. 

We have already said that until within a comparatively 
short period, searing with a red-hot iron was the means com- 
monly employed to arrest arterial hemorrhage. Stumps, 
after amputation, were submitted to this dreadful applica- 
tion, adding vastly to the terror and pain of operations which 
even now seem almost too severe for endurance. 

The cautery, by disorganizing the extremity of the vessel, 
and corrugating the animal fibre, is an effectual preventive 
of hemorrhage, and may be resorted to when there is no 
other resource. 

It sometimes happens that an injury is done to a bone, 
which opens an artery imbedded in it ; the same happens, 
occasionally, in operating upon these organs. Under such 
circumstances, it is sometimes impossible to use a ligature. 

*The actual cautery is fire or a heated body, the potential certain chemical 
substances, which combine with and destroy the tissues, as nit. of silver and 
pure potass, &c. 



270 WOUNDS OF THE MOUTH AND FACE. 

It also happens occasionally that in the extraction of a 
tooth, a vessel is ruptured which continues to bleed freely 
for hours, and even days, after the injury ; and the hemor- 
rhage is not only exceedingly inconvenient, but sometimes is 
sufficiently great to be alarming. 

Under these circumstances, after ineffectually stuffing the 
socket with lint, &c, medicated by alum, the mineral acids, 
&c, it becomes necessary to use the actual cautery. 

Owing to the very small surface to which the heated body 
is to be applied, this can be done without much pain to the 
patient, and will, if dexterously accomplished, afford prompt 
relief. 

A probe ending in a small button, or some other metallic 
body of suitable size and form, should be heated to a white 
heat and carried suddenly to the bottom of the socket. Care 
should, of course, be taken not to touch the tongue or cheeks. 

A pencil of lunar caustic (nit. argenti) pressed fairly into 
the wound will commonly accomplish the purpose. If this 
should fail, the actual cautery may be used. 

If the hemorrhage from a simple incised wound be merely 
venous, we need not be concerned about it: it will soon 
cease, unless the trunk be very large. 

The treatment of incised wounds, consists in bringing the 
edges of the wound close together and keeping them in con- 
tact. This done, nature performs the cure by throwing out 
lymph, which cements the adapted edges together, and be- 
coming organized, forms a permanent bond of union. 

When this is accomplished without suppuration, it is called 
by surgeons, "the union by the first intention." 

This mode of union leaves but a very slight cicatrix, and 
occasions the least deformity. It is, therefore, especially 
desirable in all wounds of the face and neck. 

It also is attended with the least possible contraction of 



WOUNDS OF THE MOUTH AND FACE. 271 

the parts, and is, therefore, as well as for other obvious rea- 
sons, very desirable in all wounds of the mouth. 

It will be noticed, that we propose no means for curing 
wounds. The truth is, we have none, and none are wanted. 
Nature is abundantly capable of repairing these injuries, if 
the parts be placed in a proper relation, and be protected 
from the external air, which is a positive irritant to the in- 
ternal surfaces. 

There is no virtue in salves or balsams to heal simple in- 
cisions ; but these applications may retard the cure and cause 
suppuration where none would otherwise have occurred. 

There are several means for approximating divided sur- 
faces, and keeping them in contact. They are adhesive 
plasters, sutures and bandages. 

Of these, adhesive plasters are the most important. They 
are generally sufficient to approximate the parts closely, and 
unless very great nicety be required, will generally answer 
all desirable purposes. 

The solution of gun cotton in ether, which has recently 
been introduced into surgical use, promises to supersede 
sutures to a considerable extent. 

Sutures or stitches, are threads passed through the lips of 
the wound and then tied, holding the divided surfaces to- 
gether. When very muscular and contracted parts are di- 
vided, such as the lips or the eyelids ; where it is important 
to prevent deformity ; where the wound is too deep to be 
closed by adhesive straps ; where, from the moisture of parts, 
adhesive plaster would not be available ; or when, as in la- 
cerated wounds, the parts have been broken into small and 
irregular fragments, not affording sufficient sound surface 
upon which to fasten the plasters ; in such cases, sutures are 
useful. 

Lacerated wounds bleed less profusely than simple incisions. 
The injury done to the vessels is commonly of a kind which 



272 WOUNDS OF THE MOUTH AND FACE. 

paralyzes them for the moment, or at least so far enfeebles 
their functions as to prevent active hemorrhage. 

This is sometimes the case even when large arteries are 
torn asunder. Cases have been observed where the arm has 
been torn from the shoulder by machinery, and the arteries 
left hanging out from the wound, yet no serious bleeding 
ensued. In the experiment of Dr. N. E. Smith, the carotid 
artery of a horse, when ruptured by a blunt hook passed 
under it, bled but little. The absence of bleeding in exten- 
sive lacerations, though immediately convenient, yet indi- 
cates an amount of injury to the parts far greater and far 
more difficult to remedy than that which attends incisions. 

The parts may be entirely destroyed ; or their vitality may 
be so far lessened as to make them incapable of resisting the 
inflammation which will result, and cause them to mortify. 

Wounds of this kind do not heal by resolution ; they will 
suppurate, and consequently the cicatrix that results is 
more unseemly than that left by simple incised wounds. The 
pain is generally in inverse proportion to the extent of the 
injury; small lacerations causing great suffering, while those 
which are very extensive, so benumb the sensibilities as 
to cause comparatively little. A miller, whose arm and sca- 
pula were wrenched off by a wheel, did not know what had 
happened until he saw the arm revolving round it. There 
was, as usual in cases of this kind, no serious hemorrhage. 
The indications in lacerations are to cleanse the wound of 
any foreign substances, such as sand, gravel, &c, and to unite 
the ruptured parts, as nearly as we can, without inflicting se- 
rious additional injury. 

A difference of opinion exists as to the proper application. 
Inasmuch as the part is at first cold, and the circulation 
weak, it was long a common practice to apply some stimu- 
lating applications, such as turpentine, or some spirituous 
preparation ; and when inflammation was established, to dress 



WOUNDS OF THE MOUTH AND FACE. 273 

the wound with warm poultices, in order to promote the sup- 
puration. 

The most eminent surgeons of the present day, however, 
prefer very cold applications, such as ice or ice -water, in 
order to allay the inflammation, which is sure to occur, and 
which is apt to be excessive. 

The probability is that the wound, like an incised wound, 
does better without any dressing at all, except its own blood, 
which protects it from the air and forms a soft, well-adjusted 
cushion between the wound and the bandage, which, of course, 
should be thrown around it, so as to protect it but loosely. 

The author once saw a wound of this description, of an 
aggravated character, which was treated in the way de- 
scribed, by Dr. N. E. Smith. The patient was a boy whose 
hand had been caught in an agricultural machine. His fingers 
were literally crushed; the phalanges splintered, and the 
flesh torn up and hanging in rags about the broken bones. 
The joints of the fingers were, for the most part, disorga- 
nized, and the organ presented so hopeless a condition, that 
amputation seemed inevitable, and Dr. Smith was invited to 
perform the operation. This experienced and skilful surgeon, 
while he admitted the apparently hopeless condition of the 
wound, observed, very justly, that it would be time enough 
to amputate when the parts should become gangrenous or 
some constitutional symptoms of an imperative character 
should supervene ; that injuries of the hand were not apt to 
occasion tetanus ; and that he would advise to let the hand 
alone, to see what nature would do. 

A few spiculae of bone were removed, and the hand 
was, without having been washed, bound up in its own 
blood ; after the fingers had been straightened by a few paste- 
board straps. 

To the surprise and gratification of all concerned, the 
wounds healed rapidly, and although, from loss of bone and 



274 WOUNDS OF THE MOUTH AND FACE. 

rupture of joints, the ringers remained deformed, stiff, and 
crooked, the boy finds them very much more useful than a 
stump would have been. 

Contused wounds do not differ very materially from lacera- 
tions. They, too, require to be let alone, unless the inflam- 
mation succeeding be so great as to require the treatment 
heretofore described as proper for such conditions. 

Contused wounds are generally attended by an effusion of 
blood beneath the skin, which gives the parts a black or deep 
blue appearance. As the absorbents slowly take up the ex- 
travasation, the color becomes greenish and yellowish, and 
finally disappears. 

With regard to both these kinds of wounds we may say ? 
that whatever treatment they require is demanded by the in- 
flammation which follows them, and must be modified to 
suit the degree and character of it, without regard to the 
transmatic cause of it. 

Punctured Wounds. — These are injuries made by a point- 
ed instrument, penetrating to some depth, and characterized 
by an opening very small in proportion to the extent of the 
wound. Yery often, the instrument by which the wound is 
inflicted is of a shape, designedly devised, for the purpose of 
inflicting the greatest possible amount of injury. A bayo- 
net, for instance, is triangular and pyramidical, much broad- 
er at the base than the point. Of course, it is forced into 
the body like a wedge, and bruises and lacerates the parts 
exceedingly. 

A punctured wound, other things being equal, is a much 
more severe injury than a simple incision. It is both a la- 
cerated and contused wound, and of course is fraught with 
the peculiar dangers attending such injuries. But, moreover, 
it is inflicted upon deeply seated parts ; vital organs may be 
reached; large vessels and nerves punctured; even bones 
penetrated or splintered. Wounds of the more deeply seat- 



WOUNDS OF THE MOUTH AND FACE. 275 

ed parts do not heal with the same facility as the skin ; they 
are more out of reach of dressing and manipulation ; they 
suppurate, and the matter is liable to form sacs or pouches, 
or to be infiltrated into the adjacent parts, acting as an irri- 
tant, and spreading inflammation in its course. 

The constitutional impression also is greater when deep- 
seated parts are wounded, than when superficial injuries, 
even of greater extent, are suffered. 

The danger of punctured wounds depends upon the extent, 
situation and character of the injury, and the age, constitu- 
tion, &c, of the subject. 

The indications for the treatment of a punctured wound 
are, 1st. To remove any fragment of the instrument by 
which the injury has been inflicted ; 2d. To secure any arte- 
ry which may have been wounded ; 3d. To place the part 
in the easiest and most relaxed position ; and, I am tempted 
to say, 4th. To let it alone. I am convinced that much 
injury is done by attempts to aid nature in her efforts at re- 
paration, when she is abundantly competent to complete the 
work without active assistance. Some surgeons inject sti- 
mulating applications, in order to bring about inflammation, 
which is sure to ensue soon enough if the health of the pa- 
tient permit. Others advise to lay the wound open,, and 
lengthen it so as to convert it into a deep incision. This is 
often impracticable without doing vast injury, is always 
painful, and when accomplished will not prevent the natural 
consequences of the laceration already suffered. The object 
of this practice is to prevent the accumulation of the matter ; 
but generally the matter will escape readily enough, and 
surely it will be time enough to provide for the evacuation 
of retained matter, when it shall be ascertained to exist. 

Sometimes the lips of the wound tend to heal before the 
more deeply seated parts have established their suppuration. 
This can be prevented by introducing a pledget of lint, or a 



276 WOUNDS OF THE MOUTH AND FACE. 

"tent," into the wound, and keeping it there until the growth 
of granulations from the bottom and the adhesion of the sides 
are completed. 

The tent should be removed every day, and a shorter 
introduced, from time to time, until the cure be completed. 

Constitutional symptoms are to be treated upon general 
principles. Before inflammation is established, and while 
the system is suffering from the pain and shock, opium will 
be our most important means. Should inflammatory symp- 
toms run high, blood-letting and other antiphlogistic means 
will be required. 

Gun-shot Wounds are violent contusions made by dense 
bodies moving with great momentum. The injuries thus 
inflicted are serious in proportion to the extent of the wound 
and the importance of the parts involved. These wounds 
generally bleed but little, but even when slight, and pene- 
trating only fleshy parts, they produce a remarkable consti- 
tutional shock, manifested by faintness, feeble pulse and 
muscular weakness. 

Grun-shot wounds must be treated upon the principles 
which apply to all other mechanical injuries. If the ball or 
other projectile can be removed without difficulty, it should 
be done ; if it cannot be readily found and dislodged, it is 
better to let it alone, as much more injury will be done by 
groping after it among the lacerated parts, than by its pre- 
sence. Generally it will come away in the suppuration. 
Sometimes the wound heals over it, and it may remain for 
years imbedded in bone or muscle, without causing incon- 
venience. 

The notion which prevailed formerly, that lead, when pro- 
jected by gunpowder, is poisonous to the flesh, is a mistake. 
This metal does no injury, except by its weight. 

Burns. — Injuries caused by the action of fire or heated 
solid bodies are indiscriminately called burns: when the re- 



WOUNDS OF THE MOUTH AND FACE. 277 

suit of contact with heated fluids, they are called scalds. Of 
course injuries from these agents must differ very much ac- 
cording to extent and degree ; varying from the slightest per- 
ceptible erythema to gangrene of the parts, and from a very li- 
mited to a very wide-spread wound. Indeed, under the com- 
mon name burn, as under the general term wound, are grouped 
together a great variety of injuries ; alike only in the fact that 
they are caused by fire or heated bodies. Yet it is common 
to speak of remedies for hums, as though all of these injuries 
were alike, and required the same treatment. There is no 
branch of surgery in which empiricism retains its ground as 
firmly as in the treatment of burns. A great number of ap- 
plications have been lauded as specific for these conditions, and 
when, from some terrible accident, a large number of persons 
are scalded, it is mortifying to notice the want of all agreement 
among physicians as to the proper management of the dis- 
tressing cases which clamor for relief, and the dogmatic em- 
piricism with which nostrums are insisted upon by pro- 
fessional men, who are unable to give any satisfactory reason 
for their extraordinary confidence in their own suggestions. 

Some years ago a steamboat started from the wharf in this 
city, upon a trial trip, and exploded before she had gone a 
hundred yards. Many persons who thronged her decks were 
scalded and blown into the water. When taken out, they 
were chilled and shivering, with feeble pulse, laboring under 
great constitutional irritation. 

Under these circumstances, it was painful to notice the 
modes of treatment adopted, upon opinions of specific virtue 
in certain agents, without any apparent regard to the proba- 
bility of good, as inferred from their known qualities, and 
the condition of parts to which they were applied. 

Cold water, spirits of turpentine, raw cotton, soot, soap, 
with many other applications, have been strongly advocated 
as dressings for burns; yet certainly it would require an 



278 WOUNDS OF THE MOUTH AND FACE. 

utter disregard of rational conduct to apply turpentine to 
the extended surface of an abraded cutis, or cold water to 
the shivering skin of a feeble patient, whose whole constitu- 
tional effort cannot accomplish reaction. 

The danger of burns is in proportion to extent rather than 
degree. A small portion of the body might be burned to 
complete destruction, with far less danger than a large sur- 
face could be reddened and vesicated. 

Scalds, therefore, which are superficial burns, are very 
dangerous, because, from the diffusible nature of their cause, 
they are generally extensive. 

The reason is, 1st. Because the pain of burns is the prime 
cause of the constitutional distress, and of the serious or fatal 
'consequences that ensue, and superficial burns of the skin 
are generally most painful and most extended. 2d. The skin 
has most powerful sympathies with the mucous membranes 
of the bowels and lungs, and these are very apt to assume 
serious inflammation when the skin has been extensively 
scalded. 3d. The functions of the skin are important, and 
cannot be extensively interrupted with impunity. 

From the last two causes, it happens that scalded persons 
are apt to die of pulmonary engorgement, and not because 
they have "inhaled steam,"' as has been so commonly sup- 
posed. 

Where burns or scalds are superficial, the great object is 
to protect the irritated surfaces from the air, which is most 
distressing to them. To this end, nothing is better than the 
raw cotton, which, to prevent its adhesion to the sore, should 
be moistened with some unctuous substance. Linseed oil 
and lime water mixed together are commonly used for this 
purpose, and the mixture answers very well. The cotton 
thus treated forms a soft, warm, innocent dressing, and is as 
good a substitute for the skin, (and this is what we want,) as 
we can procure. Wheat flour or other farinaceous matters 



WOUNDS OF THE MOUTH AND FACE. 279 

sprinkled on until the part is completely covered and pro- 
tected, will answer a similar purpose. For obvious reasons 
the cotton is preferable. A coating of gum Arabic, applied 
in solution, has been used with good results. 

If there be no blistering or abrasion of the surface, the 
injury being severe erythema, cold water will give imme- 
diate relief. 

Sometimes the part upon which the burn has been imme- 
diately inflicted will be disorganized or nearly so ; the sur- 
rounding parts, and those subjacent, partaking of the injury 
in proportion to their propinquity to the place of contact. 

In such cases, as the vitality of the parts is nearly ex- 
hausted, and gangrene likely to take place, the stimulating 
agents, turpentine, &c, may be very properly employed. 

In short, the treatment of burns, like that of other injuries, 
must depend upon the judgment of the surgeon, in view of 
the peculiar condition of the injury. 

Burns leave large and unseemly scars, which pucker as 
they contract, and often cause permanent deformity by the 
shortening of skin and muscles. It is important, in the 
treatment of these injuries, to guard against this tendency as 
much as possible, by preventing those positions which, though 
most easy to the patient, will permit the contraction above 
mentioned. Care must be taken, too, that two burned sur- 
faces be not brought together and kept in contact. I once 
saw a child whose hands were rendered entirely useless 
through neglect of this precaution. The palms had been 
burned, and the mother bound up the closed fists, and suf- 
fered them so to remain until palmar adhesion and permanent 
muscular contraction rendered the organ entirely useless. 

Fractures. 
A fracture is a solution of continuity of a bone, produced 
by violence, acting either by some external agent, or, occa- 



280 WOUNDS OF THE MOUTH AND FACE. 

sionally, by the sudden and extraordinary contraction of 
muscles. 

A fracture may take place transversely, obliquely, or 
longitudinally. The difficulty of adjustment and reparation 
will be in accordance with certain circumstances which give 
character and importance to the injury. 

Cseteris paribus, a simple division of the bone transverse- 
ly, or a longitudinal fissure of moderate length, will involve 
much less suffering from injury to the soft parts, and will be 
much more likely to heal without deformity, than a fracture 
which is oblique ; because, in the former cases, there will be 
but little if any displacement of the broken surfaces of the 
bone, while in the latter, the muscles attached to the separa- 
ted part are apt to draw it out of its position, and cause it to 
ride upon the fixed portion. The action of the same 
muscles is of course continually opposing the force used to 
keep the restored fragment in place. 

Fractures may be comminuted — that is to say, the bone 
may be broken into small fragments; they may be com- 
pounded, that is, may be associated with injuries, more or less 
serious, of the soft parts covering or covered by the bone, 
such as lacerations of the muscles, skin, protrusion of frag- 
ments of bone through the integuments, &c. 

Fractures are said to be complicated when attended by 
some accident or condition which materially embarrasses the 
treatment and cure. Thus a large artery may be wounded, 
an important viscus injured, or a constitutional disease, af- 
fecting the vitality of the bones, may exist. 

Treatment of Fractures. — The general treatment of fractures 
consists in meeting the following indications : 1st. To re- 
store the displaced pieces of bone to their natural position. 
2d. To keep them there ; and 3dly. To afford any additional 
aid which the nature of the injury and the constitutional 
circumstances may require. It does not always happen that 



WOUNDS OF THE MOUTH AND FACE. 281 

the fragments are displaced. In such cases the duty of the 
surgeon, so far as the condition of the bone is concerned, re- 
quires no more than to support the parts, and place them in 
such a position as will best guard against displacement. It 
will be seen that the surgeon has nothing whatever to do 
with the production of bony union. That is entirely the 
work of nature, and is accomplished by the formation of a 
hard intermediate substance, which is called callus. 

Soon after the injury, a swelling is observed around the 
broken ends of the bone, which gradually hardens until it 
surrounds the fracture with a kind of bony splint, within 
which the process of reparation goes on. This is called the 
provisional callus. As the cure advances, this hard swelling 
subsides, though it rarely entirely disappears, and the bone 
is found to be permanently united by an organized osseous 
substance, which well subserves all the purposes of the lost 
bone. 

According to the experiments of Breschet and Yillerni, 
the following are the principal circumstances remarked 
during the process of reparation of fracture. 

1. Extravasation and coagulation of a small quantity of 
blood between the ends of the fracture, which blood escapes 
from torn or ruptured vessels. 

2. A fluid, at first of a viscid quality, effused and secreted 
as it were between the periosteum and the bone, and likewise 
exuding from the surfaces of the fracture, and from the soft 
parts. 

3. A gradual increase in the quantity and consistency of 
the preceding substances blended together, forming every 
day a stronger connection between the parts; then their 
change to a red intermediate substance between the fragments 
and between the bone and periosteum to a substance which 
is at first soft, but in the end acquires the character of bone. 

19 



282 WOUNDS OF THE MOUTH AND FACE. 

4. At the fractured parts a reunion of the periosteum and 
soft parts, which are equally indurated and confused together 
with the intermediate substance between the fragments. 

5. A diminution and then an obliteration of the medullary 
cavity, at first by a cartilaginous, and then by a bony depo- 
sition. 

6. Successive ossification of the whole of the swelling com- 
posing the callus, and of the substance between the fragments, 
preceded by a fibrous and cartilaginous state. 

7. The return of the soft parts around the fracture, and 
then of the periosteum to their natural state. 

8. After the union of the surfaces of the fracture, the me- 
dullary cavity and texture are gradually re-established, and 
the swelling formed by the callus always diminishes * 

Whatever may be the process by which callus is formed, 
it is during the first two or three weeks after the fracture 
that the fragments undergo the changes which promote their 
reunion. But it is within the twentieth and thirtieth, and 
especially between the thirtieth and fiftieth days, that nature 
labors effectually in consolidating the callus. Hence, at this 
period, our care to retain the ends of the fracture in exact 
contact and perfectly at rest, should be redoubled, for though 
there are a few instances in which deformity really proceeds 
from irregular ossification, it is a fact that the deformity al- 
most always originates from the fracture being disturbed 
and not kept properly reduced.^ 

Fractures of the Jaws. — The lower jaw is liable to be fractured 
at any part of its extent, as between the symphysis and the 
masseter muscle, within the muscle, and between it and the 
angle. The bone may also be broken in two places simul- 
taneously. Sometimes, also, the condyles, and less frequently 
the coronoid processes, are broken off. 

* Cooper's Surg. Die, Art. Fractures. f Boyer. 



WOUNDS OF THE MOUTH AND FACE. 283 

Fractures of this bone may be perpendicular, oblique or 
longitudinal. Sometimes a part of the alveolar process with 
its teeth has been split off. 

"When the fracture is near the symphysis, the submaxil- 
lary muscles will draw down the part to which they are at- 
tached, while the other fragment, released from the counter- 
action of those muscles, will be proportionably elevated by 
those which close the mouth. When fractured in two places, 
the middle fragment will be drawn downwards and backwards, 
while the lateral portions will be supported by their muscu- 
lar attachments. When the fracture occurs within the mas- 
seter, little displacement can take place, as the muscle at- 
tached to both fragments keeps them in their natural position. 

Fractures of the lower maxillary may generally be detect- 
ed without much difficulty. 

If, after a severe blow or fall, there should be severe pain 
in the jaw, attended with laceration and swelling of the soft 
parts ; if the line of the bone be irregular; if crepitus be felt; 
if the gums be denuded, and if the level of the teeth be in- 
terrupted, there can be no doubt that fracture has occurred. 

Nor is it necessary that all these appearances shall be pre- 
sent in order to satisfy the observer of the nature of the 
injury. As the bone can be traced with the finger along 
its whole length, and its level observed both upon the upper 
and lower margin, the displacement or crepitation, and the 
pain or disability of motion, will sufficiently indicate the 
kind and point of injury. 

There is little difficulty in replacing the fragments of a frac- 
tured lower jaw. We have but to push the displaced part 
upwards and a little forwards, and press it exactly into a line 
with the fixed portion — observing that the teeth are also 
properly level. It is not so easy, however, to keep the parts in 
their proper place, but the upper jaw being fixed, enables us 
to sustain the lower one against it. 



284 WOUNDS OF THE MOUTH AND FACE. 

A piece of pasteboard, moistened and softened with vine- 
gar, or, if there be excoriation, with water, is first adapted 
to the basis of the jaw. A four-tailed bandage is then em- 
ployed to keep the parts in position. This consists of a piece 
of muslin or flannel, several inches wide, the centre of which 
is perforated for the reception of the chin, and the two ends 
divided longitudinally, so as to make two tails on each side. 
The anterior of these are carried up the side of the face, and 
secured to a night-cap posteriorly, and the posterior tails an- 
teriorly. The patient must keep his mouth closed as nearly 
as possible, refraining from talking, and subsisting upon fluid 
or semi-fluid food. 

Sometimes a tooth will be split in the fracture, and must 
be extracted. It sometimes happens, also, that the teeth are 
so irregular as to prevent the complete closure of the jaws, 
in which case a piece of cork may be so placed as to accom- 
plish the purpose of supporting the lower by pressure against 
the upper jaw. 

Dr. Ehea Barton, of Philadelphia, devised a bandage for 
fractures of the jaw, to which many surgeons gave a prefer- 
ence. He commences with a roller an inch and a half wide, 
below the prominence of the occiput, and continues it ob- 
liquely over the centre of the parietal bone across the junc- 
ture of the coronal and sagittal sutures, over the zygomatic 
arch, under the chin, and pursuing the same direction on the 
opposite side, until he arrives at the back of the head ; he 
then passes it obliquely around and parallel to the basis of 
the lower jaw over the chin, and continues the same course 
on the other side, until it ends where he commenced, and re- 
peats. * 

When the condyle is fractured, the external pterygoid 
muscle pulls it forwards, and it is by no means easy to apply 

* Reese, Note Cooper's Surg. Diet. 



WOUNDS OF THE MOUTH AND FACE. 285 

such a force to the deeply seated fragment as to bring it in 
contact with the body of the bone. Our only alternative is 
to press the lower portion as well as we can to the condyle, 
by placing a thick compress upon the angle of the jaw, and 
applying our bandages so as to press upon this part of the 
bone. 

Compound fractures of the jaw are to be treated as simi- 
lar injuries elsewhere. Every attention must be paid to en- 
sure cleanliness, contact and rest of the parts, and constitu- 
tional symptoms are to be met by antiphlogistics, anodynes 
and tonics, as cases may require. 

Dislocations* or Luxations. 

The forcing of articular surfaces out of their relative position 
is called a dislocation or luxation, or familiarly, putting out 
of place. These injuries require surgical aid, it being rare- 
ly possible for the patient to replace the bone by his own 
efforts. 

The cause of dislocations is generally external violence, 
especially falls, but they may be occasioned by the sudden 
and violent contraction of muscles, and these latter are always 
more or less concerned both in effecting dislocation and re- 
pairing it. 

Luxations may be complete or incomplete. They are com- 
plete when the articular surfaces no longer touch ; incomplete, 
when they remain partially in contact. 

They are necessarily attended with rupture or violent elon- 
gation of ligaments. 

The symptoms of dislocation are pain and incapacity of 
the part, change of position and relation of the bones which 
form the joint, ascertained by the touch and by the position 
of the limb or part. Sometimes, also, special symptoms, in- 

* Dis loco — to get out of place. 



286 WOUNDS OF THE MOUTH AND FACE. 

dicating the pressure of bone upon sensitive or important 
parts, attest the nature of the injury. 

Dislocations of the Lower Jaw. — From the latitude of motion 
enjoyed by the lower maxillary bone, and the necessary 
looseness of its articulation, it is very subject to dislocation, 
though this can only take place in one direction, forwardly, 
and not then unless the mouth be wide open and the chin de- 
pressed greatly at the moment of the injury. 

Sometimes when parties are in high altercation, and one 
of them is vociferating loudly, a blow from the other, falling 
upon the expanded jaws, will put a stop to the flow of epithets 
or recital of grievances, by dislocating the submaxillary. 
Sometimes, also, after the jaw has been previously dislo- 
cated and the ligaments relaxed, yawning will be sufficient 
to bring the condyles to slide forward, and the ligaments 
giving way, to glide beneath the zygoma. 

The injury has resulted from the use of great force in ex- 
tracting a tooth, the jaw being much depressed at 'the same 
time that great force was exerted upon a posterior tooth, ele- 
vating and pulling forward the posterior part of the bone. 

Dislocations of the jaw are very painful, owing to the pres- 
sure of the condyles upon the deep-seated temporal nerves, 
and those which go to the masseter, which nerves pass before 
the root of the zygomatic processes. — (Boyer.) The mouth 
is open and immovable, the patient speechless, the saliva 
running from the mouth, and the countenance expressing 
great distress and anxiety. If the dislocation be long con- 
tinued, the jaws are more nearly approached than when the 
injury is recent. The coronoid process forms under the 
cheek bone a prominence which may be felt through the 
cheek or from within the mouth.* 

Upon the whole, it is not easy to mistake the character of 
the injury. 

* Cooper's Surg. Diet. 



WOUNDS OF THE MOUTH AND FACE. 287 

Dentists should be aware of the possibility of such an acci- 
dent as this when extracting a tooth, and should guard against 
such a position of the jaw as would be favorable to it. It 
may happen, however, even in the hands of the most skilful 
and prudent, and they should be prepared to reduce the dis- 
location immediately. 

Mr. Fox dislocated the jaw of a patient on both sides, while 
endeavoring to extract a tooth for him. 

The manner of replacement is very simple. The operator 
must first wrap his thumbs thickly with cloth of some kind 
to protect them from injury. He must then place them as 
far back in his patient's mouth as he can, and while he de- 
presses the posterior part of the jaw with them, he must ele- 
vate the chin with his palms and fingers. This process 
disengages the condyles from beneath the zygoma, when the 
muscles draw them into their place with considerable force — 
enough to lacerate the thumbs of the surgeon, unless they 
have been well guarded against such an accident. 

Sir Astley Cooper placed the patient in a recumbent pos- 
ture, placed two corks between his molar teeth, and elevated 
the jaw. 

Efforts at reduction may be confined to one side, if one 
only be dislocated. 

In order to prevent a redisplacement, the jaw should be 
supported for several days, by bandages similar to those em- 
ployed for fracture of the lower jaw, and the patient should 
be warned against opening his mouth more than absolutely 
necessary for the reception of soft food. 



CHAPTER XVI. 

PAETICULAE AFFECTIONS OF THE MOUTH AND ADJACENT 

PAETS, 

Diseases of the Gums. 

Of inflammation of the gums I have already treated, in 
considering the general subject of inflammation. They are 
liable to other disorders which are worthy of notice. Among 
these are tumors, termed epulis'* and parulis.f These tu- 
mors differ entirely in character. The parulis is an abscess, 
the result of suppurative inflammation; the epulis a true 
tumor or morbid growth, seated upon and involving the 
structure of the gum. Parulis is therefore a distention of 
the parts by injected blood and effused matter; parulis is an 
addition of organized but unhealthy substance, increasing 
the solid bulk of the parts. 

The term epulis is applied to different excrescences seat- 
ed upon the gum. Some are hard, even scirrhous, others 
soft and spongy. Some are developed in the gum itself, 
others have their seat in the membranes of the teeth, perios- 
tea, or in the dense structures of the bones. 

Of course, as they differ in character and in seat, they can 
have no uniformity as to the inconvenience and danger at- 
tending them. They are generally caused by carious teeth, 
whose fangs keep up a continual irritation in the neighbor- 
ing parts, and are sometimes traceable to neglected parulis 
or gum boil as their immediate cause. 

* Epulis — em — upon, — ovlov — the gum. 
f Parulis — napa — near, — ovlov — the gum. 






AFFECTIONS OF THE MOUTH. 289 

The most common form of epulis is that of a soft, red, 
spongy mass, which bleeds readily, but is not attended with 
much pain, as it is not very sensitive. It is liable to be re- 
produced after removal, but, unless improperly treated, is 
not dangerous. Sometimes, instead of appearing externally, 
the disease commences in the sockets of the teeth, and 
loosens and displaces them, though they may be perfectly 
sound. Some swelling of the gums and a discharge of pus 
accompany this condition. 

A smooth, shining, elastic tumor sometimes shows itself 
upon the gum. It is compressible, but little sensitive, and 
bleeds freely if cut into. It is not malignant. Mr. Tomes 
recommends the application of powdered tannin. 

A scirrhus may be located in the gum, where it will exhi- 
bit its distinctive qualities, hardness, acute lancinating pain 
and Unequal surface. It follows the history of similar tumors 
elsewhere, and is much to be dreaded. 

Another form of carcinomatous affection of the gums is 
that of a soft, spongy, bleeding fungus, much like the first 
form of epulis, but accompanied with great sensitiveness and 
acute pain. 

When these affections, either in their natural progress or 
from ill treatment or injury, assume a rapidly progressive 
form, very terrible phenomena begin to manifest themselves. 
If previously hard, they soften, the bones become carious, a 
fetid and sanious discharge is poured out, the teeth are 
loosened, the devastation spreads, the lymphatics swell, hectic 
supervenes, and after much severe suffering the patient ex- 
pires, from nervous exhaustion, hemorrhage or suffocation. 

When the tumor is of the non-malignant kind, and has 
not so far progressed as to involve a large mass of bone in 
caries, and soft parts in ulceration, it may readily be re- 
moved, and its return prevented, by the removal of the ca- 
rious teeth which cause it, if, as is generally the case, it has 



290 AFFECTIONS OF THE MOUTH. 

been induced by this cause. Without removing these irri- 
tants; of course no permanent cure can be expected. 

When of the malignant variety, the most prompt and de- 
cided means must be resorted to, to prevent fatal conse- 
quences. 

Mr. Liston and Prof. Mutter both regard genuine cancer 
of the gums as a very rare disease; but they concur in 
thinking that such affections are degenerations from original 
character, owing to constitutional causes, neglect or bad 
treatment. There is, therefore, more encouragement to hope 
for success in the attempts made to remove these affections 
than when they are but the local indications of general dis- 
order. 

The treatment will of course be modified by circum- 
stances. If the disease be not malignant, but is evidently a 
mere fungous condition of the gums, depending upon the 
irritation of a carious tooth, &c, it is only necessary to re- 
move the cause of the trouble, and then to cut away the tu- 
mor, and destroy what may remain of it by compression or 
caustic. 

If the tumor be of the elastic kind, it must be thoroughly 
removed. If it hang by a narrow neck, it may be cut off by 
a ligature. Profuse bleeding is apt to result from incising 
these tumors, and will generally demand the use of the actual 
cautery for its suppression. 

The scirrhous or malignant tumor requires a very 
thorough exsection. Every tooth and all the bony structures 
in any way connected with it must be boldly cut away, and 
the wound seared with the hot iron. 

The mode of operation preferred by Prof. Mutter, and 
which he thinks "better adapted to the case," and fraught 
with less suffering than the use of the mallet and chisel, is 
thus described by himself.* 

* Liston and Mutter's Surgery, p. 285. 






AFFECTIONS OF THE MOUTH. 291 

"Having placed the head of the patient in a good light 
and against the chest of an assistant, who stands behind the 
operating chair ; the surgeon makes a perpendicular incision 
on each side of the tumor, with a pair of strong scissors, or 
rather cutting forceps, and without stopping to arrest the 
hemorrhage, at once detaches the mass, by dividing the alve- 
olar process above or below the tumor, as the upper or lower 
jaw happens to be involved, with cutting forceps, one blade 
of which is applied to the inner portion of the jaw, and the 
other to the outer. The raw surface is next carefully exa- 
mined, and every vestige of the disease removed, with a 
knife or scissors. If the bone appears affected, it must be 
cut away, and often a very good preventive to the return of 
the disease is the use of the actual cautery. The bleeding 
may be arrested, either by the cautery, or by placing a 
pledget of lint, dipped in creosote, in the chasm, over which 
a slice of cork may be laid, and then closing the jaws, make 
the sound one act as a compress. To secure the dressing, 
the bandage for fracture of the lower jaw may be applied. 
The parts should not be examined in the first twenty-four 
hours ; but after this period a daily dressing is required, the 
nature of which depends on circumstances. If there be no 
disposition to a return of the disease, it will be sufficient to 
wash the part with some detergent solution, until cicatriza- 
tion is completed. But if fungous granulations make their 
appearance, the vegetable caustic, (caustic potassa,) or actual 
cautery, should be applied, until this disposition in the wound 
is destroyed. 

"Instead of using the perpendicular cuts with the short 
forceps, some prefer a thin saw, but the method just described 
is less painful, and accomplishes the object in a much shorter 
period. When the tumor is very large, the saw may be re- 
quired, and should be always at hand, in case the edges of 
the forceps should turn in making the first cut. 



292 AFFECTIONS OF THF MOUTH. 

"When the tumor is very large, or seated in the side of the 
bone, or far back, the cheek should be divided, in order to 
enable us to reach it without difficulty. In such cases I have 
found great advantage in using a cutting forceps, so curved 
as to pass readily to the back part of the mouth, and then 
allow of the blades being passed above the base of the tumor, 
when the upper jaw is affected, and below it, when the infe- 
rior maxillary is the seat of the disease. 

"After the removal of the diseased mass, the wound of the 
cheek may be closed, and union by the first intention at- 
tempted ; and when the dressings are carefully attended to, 
the deformity resulting from the incision is scarcely percepti- 
ble, unless the portio dura is extensively injured, when para- 
lysis, generally incurable, ensues, often giving rise to a very 
unpleasant expression of countenance." 

Of whatever kind these tumors may be, they should be 
carefully watched. So long as they cause no inconvenience, 
they may be let alone, but if, by reason of growth or any 
other cause, they begin to inflame the surrounding parts, or 
to become painful during the movements of the jaw or con- 
tact with air or food, they should be extirpated. If pendu- 
lous and accessible, a ligature or the knife may be used ; but 
if broadly based and fully incorporated with the gum, and 
but small in size, caustic should be used. 

A number of cases have been collected by Jourdain, and 
published in his celebrated work on the diseases of the mouth, 
which show the serious character often assumed by epules. 
In truth, all forms of tumors may appear upon the gum, and 
the only difference to be observed in their treatment in this 
location, grows out of the impossibility of using applications 
and appliances which are found useful and convenient else- 
where. So far as tumors of the gums are concerned, the 
treatment is very limited indeed. If they contain matter, 
they must be opened; if connected with carious teeth, these 



AFFECTIONS OF THE MOUTH. . 293 

must be removed ; if with carious alveoli or maxillary bones, 
the treatment must be directed to the deep-seated cause ; if 
they are malignant, or if in any way inconvenient, they must 
be removed, either by cautery, ligature or incision, as the 
nature of the case may require. 

In by far the greater number of cases, epulis is nothing 
more than irritation of the gum, manifested by fungus or 
polypoid growth, and depending for its continuance and de- 
velopment upon the continued action of the primary irritant 
— a decayed tooth with a ragged edge, or a stump overlapped 
by exuberant gum, which is pinched against it in mastica- 
tion. Between diseased and broken teeth the gum is apt to 
send up unhealthy growths, and these being often compressed 
and lacerated become more and more inflamed and enlarged, 
and may suppurate and put on the appearance of malignant 
ulceration. It is not often that we see diseased gums of this 
character, except as the accompaniment of worn and carious 
teeth, the removal of which is all that is necessary to cure. 

Cases have occurred where the tumor owed its origin to 
small detached pieces of bone, which failing to escape by 
suppuration, had become permanent irritants, and begotten 
irregular nutrition. As the secret cause was enclosed in the 
tumor, it could not be discovered until the morbid growth 
had been excised. Of course, where no apparent cause can 
be detected, excision of the tumor is the only course, unless 
it can be destroyed by caustic, with less suffering and danger. 

In a case treated by Mr. De Morgan, the tumor contained 
an isolated piece of bone which was imbedded and entangled 
in the fibrous tissue. Upon careful examination it proved 
to be a piece of alveolus detached by absorption. In another 
case, the stump of a tooth, the crown of which had been 
broken off five years before, was found in the centre of an 
epulis. — (Tomes.) 

Parulis. — Abscess of the gum is so called. It is precisely 



294 AFFECTIONS OF THE MOUTH. 

similar to such tumors in other soft parts, and generally, if 
not always, depends upon carious teeth. 

Sometimes the abscess makes its appearance without pre- 
ceding pain, over the fang of a diseased tooth, and after re- 
maining for some time will gradually disappear, the matter 
it contains having been absorbed, or having found vent 
through an opening in the tooth. More commonly, however, 
the abscess succeeds a violent and protracted tooth- ache, 
which is the consequence of cold acting upon the irritable 
nerves of carious teeth and bad- conditioned gums. The pain 
is sometimes very severe, but at all times there is an aching 
or throbbing sensation, due to the inflamed state of the gum 
tissue. Sometimes several days and nights of severe suffer- 
ing will elapse before the abscess is seen to elevate itself from 
the gum: at other times it will be formed in a few hours. 
When first perceived, it is a hard circumscribed elevation, 
either immediately upon the gum or in the cellular tissue 
between the gum and cheek. After a longer or shorter time, 
the tumor softens, the pain abates, and fluctuation is per- 
ceived in the tumor. If no artificial means be employed to 
evacuate the matter, an opening will be made and the matter 
discharged. Sometimes, though very rarely, ulceration will 
perforate the cheek, and the pus be evacuated on the outside. 
This is an accident much to be deplored, and, therefore, as 
soon as fluctuation is perceived between the gum and cheek, 
the pus should be evacuated. 

During the inflammatory stage of the tumor, before pus is 
formed, little can be done except to apply leeches to it. This, 
if applied very early, will sometimes prevent suppuration, 
and more often limit its extent. After the tumor is fully 
formed, however, leeching will do no good. We can only 
soothe the patient by keeping the face warm, by applying 
counter-irritants to the cheek, and prescribing anodynes. 



AFFECTIONS OF THE MOUTH. 295 

Unless the diseased tooth be removed, the abscess will be 
formed again upon the slightest provocation. 

Generally, after the evacuation of the pus, the abscess is 
filled with granulations, and the parts return to their natural 
state. Sometimes, however, the tumor is due to slow sup- 
puration of the fang or alveolus, and in this case the matter 
continues to trickle through the opening, the edges of which 
become thickened and hard, and a fistula is formed. 

Of course, the only remedy is to remove the diseased tooth 
or bone. 

It not unfrequently happens that abscesses are formed at 
the roots of teeth which appear sound, and after much pain 
endured by the patient, fistulous openings evacuate the mat- 
ter which should have been discharged by extracting the 
tooth or teeth whose obscure disease produced and per- 
petuated the trouble. In illustration of this important fact, 
I will quote some cases reported by Jourdain. 

"The late Mr. Desjardins, surgeon, requested me to visit 
with him M. Kose, Place de Greve. 

" This patient had been suffering for many days such vio- 
lent pain along the whole extent of his chin, as to prevent 
him from sleeping at night or pursuing his business by day. 
As no disease could be discovered in his teeth, and as they 
were not at all subject to ache from cold or heat, they were not 
suspected to r>ause the suffering. The patient was bled, but 
without effect, and the pain becoming excessive, I was called 
in. I first examined the lower incisors, but could discover 
no signs of disease. The other teeth also appeared sound. 
The lower part of the gums of the incisors appeared slightly 
reddened, but without swelling or fluctuation. A little pur- 
ple exanthema upon the right gum was the only additional 
alteration that we could perceive, and this was not sufficient 
to determine the extraction of the tooth. 

" Thus uncertain how to act, I applied a lighted taper to these 



296 AFFECTIONS OF THE MOUTH. 

two teeth. From the reflection of the light, we satisfied our- 
selves that the incisor tooth nearest to the canine was the 
cause of all the suffering. The enamel substance seemed to 
have lost its usual transparency. Finally, to be more certain, 
I pierced the exanthema, and serous blood flowed out. The 
stilet pierced the bone and struck the root of the tooth, 
which I extracted. We immediately broke it. The canal of 
the root and the pulp -cavity were filled with a black and 
very fetid pus. 

" Upon the same day, the patient became entirely easy, 
and in a few days no appearance of disease remained." 

" Fistula of the Gum of the Lower Maxillary, having an Ex- 
terror Opening at the Hollow of the Chin. 

"M. A. Petit called me to see the wife of M. Despinasse, 
whom he had been treating for a long time for a fistula of the 
gum, situated at the lower part of the gums of the two cen- 
tral incisors of the lower jaw, and which had an external open- 
ing upon the fossa of the chin. The teeth were neither loose 
nor altered in color. 

"The patient could give no reason for the occurrence of 
the disease. She looked very well, and was yet young. The 
ulcer gave us no clue to the cause of it. The condition of 
the teeth made us hesitate to extract them from the mouth 
of so young a woman, and the same reason had hitherto pre- 
vented such an operation. 

"Various caustics had been introduced into the external 
opening. In. short, with the exception of the actual cautery, 
no means had been left untried to heal the fistula. The open- 
ing of the gum had indeed cicatrized, but that of the chin had 
proved intractable. 

"Upon exploring the outer opening, I found that the probe 
penetrated the base of the alveolar and maxillary substance, 
and that these bones were traversed by little canals corre- 



AFFECTIONS OF THE MOUTH. 297 

spending to the roots of the teeth. Hence, considering the 
length of time that the disease had resisted all remedies, I 
strongly suspected that the alveolar extremities of these roots 
were carious. I imparted my suspicions to M. Petit, who 
agreed with me that the teeth should be extracted. When 
the teeth were drawn, I examined them. The extremities of 
their roots were black and corroded ; the canal was in the 
same condition, and the pulp -cavity contained thick and fetid 
pus. Suitable treatment was now addressed to the carious 
bones, and fistulas soon were healed." 

Spongy or Fungoid Inflammation of the Gums. 

This affection is commonly called scurvy, but improperly 
so, as we have already observed. 

The gums, when thus affected, are darker than usual, 
swollen and less firm than when in health. They bleed freely 
under the brush, or when touched by the lancet, and upon 
pressure, discharge a very fetid pus, which often gives its 
disgusting odor to the breath. 

The gums are generally detached to some extent from the 
teeth, and their margins are thickened. They are often very 
sensitive. 

The extent of the disease, and the inconveniences attending 
it, vary very much. Sometimes it is confined to a very small 
portion of the gum, being a mere local attendant upon some 
diseased or irregular tooth, at other times it seems to depend 
upon constitutional causes, and communicates itself rapidly 
to the whole gum structures of the mouth. 

When thus extensive, it develops disease in the periosteum 
of the teeth, causes bone to be deposited in the sockets, 
spreads carious devastation along the whole circle of the 
jaws, and despoils the mouth, either by causing the teeth to 
be pushed from their sockets, or by destroying the crowns 
by devastating caries. 
20 



298 AFFECTIONS OF THE MOUTH. 

In the meanwhile the general health suffers. The fluids 
of the mouth are no longer fit to perform their office ; the 
teeth cannot masticate the food ^ fetid pus and blood trickle 
into the stomach, and the patient's nervous system is worn 
out by frequent paroxysms of tooth-ache. 

Though certain aptitudes of constitution give virulence to 
this affection, it is mainly a local disorder, originating from 
the presence of decayed teeth and tartar. The latter, gradu- 
ally detaching the gum from the teeth, produces inflammation 
and ulceration of the gum, and accumulating under the 
opening, constantly increases the irritation. 

Dr. Harris mentions a form of this disease met with in 
persons of scrofulous habits, which he thinks differs essen- 
tially from the more common affection. In this case, "the 
gums, instead of being purple and swollen, are paler and 
harder than ordinary, and on being pressed exude a muco- 
purulent matter of a dingy white color. They often remain 
in this condition for years, without appearing to suffer any 
loss of substance, or to affect the alveolar processes. This 
variety of disease of the gums is principally confined to per- 
sons who have very white teeth, and is much less likely to 
affect males than females. It rarely occurs before the age 
of eighteen or twenty, and though unquestionably the result 
of inflammation, yet the gums exhibit no inflammatory symp- 
toms, but on the contrary are paler, less sensible, and pos- 
sessed of less warmth than usual. It is never attended 
with tumefaction of the gums, and by absorption only in its 
advanced stages. Its effects are the most simple and inno- 
cent of any form of disease to which the gums are liable, but 
its cure is generally more difficult." 

The treatment of the common form of the affection is 
simple and generally successful, yet it is often comprehensive. 
Every irritant to the gum, whether tartar or teeth, must be 
thoroughly removed. This remark applies not only to dis- 



AFFECTIONS OF THE MOUTH. 299 

eased but even to irregular teeth, and to those which have 
no antagonists. This work of purgation of the mouth being 
thoroughly done, simple astringent washes will do all that 
is further necessary. 

The scrofulous form of the disorder described by Dr. 
Harris, demands entirely different management. Being but 
a phenomenon of general constitutional vitiation, it can 
hardly be permanently relieved by local treatment. Con- 
stitutional remedies, such as proper diet, exercise, air and 
clothing, iodine and cod liver oil, should be prescribed. 
At the same time, the edges of the gum should be touched 
with lunar caustic, ( nitrate of silver,) which not only acts 
as an escharotic by removing the diseased surface, but exerts 
a singularly modifying influence upon certain forms of in- 
flammation. 

Hemorrhage from the Gums. 

The gums, like other mucous structures, are sometimes so 
engorged with blood, that it is exuded freely upon the sur- 
face, constituting passive hemorrhage. The pathological 
condition attending this sort of bleeding is very different 
from that which is manifested by active hemorrhage. In the 
former case, the exudation of blood is caused by the weak- 
ness of the containing tissues ; in the latter, by the violence 
of vascular action. To relieve the one, we endeavor to for- 
tify the parts by astringents, &c; in the other, to lessen the 
arterial force by which the blood is injected into the distend- 
ed vessels. Hemorrhage of either kind may be due to the 
rupture of a vessel. This, however, is not necessary to he- 
morrhage, even when profuse. It is much more apt to be the 
case in active than in passive bleeding. 

The hemorrhage from the gums is always passive. Even 
when the tissues are the seat of violent inflammation, they do 
not bleed, but when they are softened and rendered less re- 



300 AFFECTIONS OF THE MOUTH. 

sisting by local or constitutional causes, they sometimes per- 
mit the blood to exude through them to an alarming amount. 

When the mucous membrane of the gums is thus hemor- 
rhagic, the condition is shared by the membrane covering 
other parts of the mouth. 

I have seen this affection as one of the phenomena attend- 
ing exhaustion from intemperance. 

Occasionally persons are met with, who manifest the he- 
morrhagic diathesis as an organic idiosyncrasy. In such 
cases all wounds are exceedingly dangerous, as the blood 
has too little coagulability to form a plug to any divided 
vessel. Instances have occurred, in which persons thus con- 
ditioned have bled to death from the rupture of trifling ves- 
sels in the extraction of a tooth. 

When passive hemorrhage occurs from the gums, astrin- 
gents generally fail to check it. Indeed, it is almost impos- 
sible to apply them effectually to every part of the bleeding 
surface. 

We have, however, a very available remedy in compres- 
sion, which can be speedily and easily applied, by filling a 
wax-holder, such as is employed for taking impressions of 
the mouth, with wax, previously softened in warm water, 
and then applying it in such a manner as completely to im- 
bed the teeth and gums in It. This method, recommended 
by Dr. O. Holmes, I have seen tried successfully in a very 
obstinate and dangerous case. 

When troublesome bleeding results from the extraction of 
a tooth, it may be checked by the actual cautery, or by plug- 
ging the tooth with a cone of waxed cloth or cork. 

The nitrate of silver will commonly arrest the hemorrhage 
promptly ; but it will not always be applied with sufficient 
accuracy to the bleeding point. A leaf of matico may be care- 
fully introduced and covered with small pieces of lint pressed 



AFFECTIONS OF THE MOUTH. 301 

into the alveolus until it is full. This should be surmounted 
with a hard compress of linen sufficiently elevated to obtain the 
pressure of the opposite jaw. Lint saturated with alum 
water, or powdered with alum, will answer a similar purpose. 

Inflammation of the Teeth. 

The organized parts of the dental structure, like other 
vascular and nervous parts, are liable to inflammation. 

As the sensitive parts of the tooth are naturally covered 
and protected by the enamel and dentine, they are little ex- 
posed to the action of causes that produce inflammation, until 
the covering structures be broken away or perforated. When 
this is the case, the pulp becomes exposed to the action of 
irritating substances, and to mechanical injury, and exhibits 
great readiness to irritation and those vascular and nervous 
conditions which we call inflammatory. 

Even when the pulp is not exposed it may become in- 
flamed by sympathy — that is, through its connexions with 
other teeth, or it may share in constitutional disease, or it may 
be kept in a state of irritation by the morbid condition of the 
superimposed dentine, and finally become inflamed and dis- 
organized before the cavity has been perforated. 

Very commonly, however, inflammation of the pulp results 
from perforation of the cavity and the introduction into it of 
air, fluids and particles of food; the inflammatory attacks 
being determined by exposure to cold, or by wound of the 
pulp in mastication, or the application to it of some acid or 
pungent substance taken into the mouth. 

The phenomena of an inflamed, or rather of an exposed 
pulp, vary with the many various circumstances of the case, 
of which natural sensitiveness of the dental nerves is one. 

There is often some unusual sensation about the tooth, as 
of soreness or elongation, subsequently a gradual increase of 
this uneasiness, which deepens into severe pain. Quite as 



302 AFFECTIONS OF THE MOUTH. 

frequently the pain comes on with a severe pang occasioned 
by the irritation, by food or pressure in eating, or exposure 
to cold. This often passes off in a few minutes after the re- 
moval of the immediate cause, but with every recurring at- 
tack the disposition to relief lessens until full paroxysms of 
tooth-ache are instituted, or in other words until the inflam- 
mation runs through its perfect course, and terminates in the 
formation of abscess. 

Though the inflammation may commence in the cord, pulp 
or periosteum, and be confined to any one of these structures, 
yet in prolonged attacks of tooth-ache, all the sensitive parts 
of the organ and the adjacent soft parts are commonly impli- 
cated, and the resulting abscess may be formed either in the 
cavity or at the extremity of the fang, or in the gum, cheek 
or palate. The tumefaction of the cheek is often very great, 
though, in such cases, the abscess, which is generally formed 
at the junction of the cheek and gum, is very small, compared 
with the swelling that precedes it. This swelling sometimes 
extends to the salivary glands, and even to the tonsils, con- 
temporaneously with the swelling, the sharp stinging charac- 
ter of the pain is changed to a deeper aching throb, or to a 
more diffused and tolerable uneasiness, which may continue 
for six or seven days, or even for several weeks, with alter- 
nations of aggravation and relief. 

Generally there is some fever, and the continued pain ren- 
ders the patient sleepless and miserable. The inflammation 
at length subsides by the formation of abscess and the dis- 
charge of pus; a very small quantity of which represents 
the product of a severe, extensive and long- continued inflam- 
mation. 

The symptoms of inflammation differ somewhat according 
to its immediate seat in the dental parts; when the pulp 
only is inflamed, there is less sensitiveness of the tooth upon 
pressure against the opposite tooth. The pain is pungent, 



AFFECTIONS OF THE MOUTH. 303 

and readily aggravated by hot or cold fluids taken into the 
month. It is sometimes speedily allayed by anodyne or 
other odontalgic applications introduced into the cavity; 
when the cord is affected, the pain is seated more deeply in 
the jaws; it may be very severe, but it has not the peculiar 
pungency of the pain which characterizes the inflamed pulp, 
and is not so much affected by hot and cold liquids. On con- 
traction an abscess is often found at the extremity of the root. 
When the periosteum is inflamed, the tooth feels elongated, is 
very tender to pressure, and often somewhat loose in the 
socket. The pain is deep-seated, and commonly extends 
over a considerable space. 

The pulp is often destroyed by a single attack of acute in- 
flammation, but always by successive attacks, which are sure 
to occur as long as the nerves and vessels, naturally covered 
by bone, are exposed to contact and compression. 

The tooth cavity then loses sensitiveness, having become 
a receptacle for disorganized matters and purulent secretion. 
Yet it will be liable to ache as long as the periosteum or cord 
preserves any vitality, and even after the complete death of 
the tooth, its presence in the alveolus may produce chronic, 
and even acute inflammation in the surrounding parts. 

Chronic inflammation of the pulp may be a primary form 
of disease, and may occur independently of caries, but com- 
monly it is consequent upon acute inflammation, and becomes 
the abiding state, of a part at least, of the pulp when unco- 
vered ; acute attacks occurring from time to time upon suffi- 
cient provocation being offered. The pain is not constant, 
indeed, except under the immediate influence of some irri- 
tating cause the tooth does not ache, though it is more or less 
sensitive to touch and pressure, and the gum is somewhat 
swollen and subject to frequent abscesses. The pulp at the 
exposed point is red and evidently inflamed, and discharges 
more or less of purulent matter, the odor of which is readi- 



304 * AFFECTIONS OF THE MOUTH. 

ly detected. Sometimes the surface of the pulp becomes a 
very painful ulcer, and sometimes shoots up exuberant fun- 
gous granulations, which bleed freely, discharge a very offen- 
sive secretion, but are not necessarily very sensitive. 

Under the action of chronic inflammation the pulp some- 
times gradually disappears without symptoms sufficient to 
attract attention. 

Eemarking upon the fact that the exposure of the pulp 
does not always occasion pain, Mr. Tomes observes : " It is 
important that the fact should be kept in view, for should it 
be assumed that the pulp is not exposed because the patient 
has not suffered from toothache, and a plug be introduced, it 
is highly probable that the tooth will be lost. The discharge 
will be blocked in by the plug, and its accumulation will, in 
the course of a short time, bring on an acute inflammation of 
the whole pulp. It is therefore of great consequence, before 
proceeding to treat a carious tooth, to ascertain whether the 
pulp be exposed or not. The history of the case will not al- 
ways determine the question, and the position of the tooth, 
or the cavity in it, may be such as to render a satisfactory 
inspection difficult. The presence, however, of that peculiar 
phosphatic odor to which allusion has been already made, 
is a tolerably sure indication that the pulp is exposed, and 
that a secretion escapes from its surface." 

Causes. — Changes of temperature, retrocession of cutaneous 
diseases, suppression of accustomed discharges, the transla- 
tion of gouty or rheumatic conditions from other parts, and 
the effect of osseous concretions in the cavity of the teeth, 
are enumerated among the causes of dental inflammation, but 
those are rarely operative upon sound teeth, and some of 
them very rarely, if ever, operative at all. The common 
cause is caries ; which, exposing the soft and sensitive parts 
of the tooth, makes it liable to direct injury, and causes a 



AFFECTIONS OF THE MOUTH. 305 

condition of morbid irritation which predisposes to inflam- 
mation under circumstances which otherwise would be harm- 
less. 

The nature of caries is not yet satisfactorily ascertained; 
some consider it to be a mere chemical erosion of the enamel 
and dentine, others regard it as a disease of the dentine itself, 
to which the chemical erosion incident to perforation of the 
enamel is secondary. 

It is certain that while the chemical constitution of the 
dentine and enamel is the same, the liability to caries in in- 
dividuals is widely different. There is certainly a constitu- 
tional peculiarity to the disease, and this is transmissible 
from parents to children. Devastation of the teeth, in some 
families, begins almost with their appearance, and no care- 
fulness or assistance of art can long prevent the ruin of these 
organs. Other persons are born with indestructible teeth, 
which the service of a long life fails to wear away, and which 
prove impregnable to food and drink, tobacco and uncleanli- 
ness. Whether the disease depends upon the perforation of 
the enamel or not, it is certain that the perforation and the 
consequent results are themselves incident to defective or- 
ganizations of the teeth. 

Dr. Grood says, "Caries sometimes begins on the internal 
surface of the tooth, and extends outwardly, exhibiting 
usually as the first evidence of its existence a black spot be- 
neath the enamel." But this observation is not borne out by 
practical dentists, who very generally maintain that some 
opening through the enamel precedes the commencement of 
caries, which however may unobservedly penetrate into the 
dentine, and undermine the enamel which at length is broken 
in, revealing a carious excavation. 

Mr. Tomes, who has investigated the subject with great 
carefulness and ingenuity, shows very clearly that the pri- 
mary cause of caries, is in demonstrable deficiency in the 



306 AFFECTIONS OF THE MOUTH. 

quantity and quality of the enamel, and in similar imperfect 
organization of the dentine itself. The latter he shows to 
be organized and susceptible of vital acts, and of course lia- 
ble to modifications of those vital acts, or to disease. Im- 
perfect enamel admits acid secretions or other irritants and 
solvents, and under the conjoint action of chemical and vi- 
tal processes, the dentine is destroyed with a facility propor- 
tioned to the imperfection of its 'structure. When the den- 
tine is hard and resistant, caries progresses slowly, and may 
be long retarded by art ; where it is porous and soft, caries is 
rapid, and the resources of the dentist are less successful, or 
almost impotent. 

The treatment of dental inflammation is simple, but often 
unsuccessful, General depletion is not often required; — ne- 
ver, indeed, except to meet a determination of blood to the 
brain, or an extent of inflammation and constitutional vascu- 
lar excitement, seldom occurring. A full dose of opium, 
about two grains to an adult, will often give prompt relief, 
tranquillizing the patient, and procuring a profound sleep. 
In the neuralgic form of toothache, and in the early stage of 
inflammation, before abscess is formed, this treatment is the 
best that can be instituted. Leeching the gums is also very 
beneficial in the beginning. Two or three leeches will pro- 
cure bleeding from the swollen gum, for several hours, and 
frequently resolve the inflammation. After abscess is formed, 
however, leeching will do little good, and sometimes the bites 
aggravate the affection. 

Warmth to the face is generally soothing, and anodyne 
substances, such as hops, and laudanum, may be applied in 
emollient poultices. Considerable relief is sometimes ob- 
tained from counter-irritants applied to the cheek, angle of 
the jaw, and neck. Mustard, ginger, pepper, &c, are used 
for this purpose. After the abscess is formed, and the pre- 
sence of matter in it well ascertained, it should be opened. 



AFFECTIONS OF THE MOUTH. 307 

This is particularly necessary when the cheek is involved, 
and there is danger of the abscess opening externally. Other- 
wise an ngly permanent scar will result. 

Prompt relief is sometimes obtained by introducing into 
the cavity of the aching tooth an application of an anodyne, 
or of a paralyzing character. Of the first, opium, in the solid 
form, or in tincture, (laudanum,) or in the form of morphia, 
is frequently used. With children, whose toothache is more 
commonly neuralgic than inflammatory, such an application 
often succeeds. But care should be taken that no more be 
used than it would be safe for the child to swallow. In the 
case of adults opium as a local application fails, but creosote 
very often succeeds, probably by obtunding the sensibility ; 
and by coagulating some albuminous matter and thus form- 
ing a covering for the exposed pulp it often presents re- 
currence of toothache for a considerable time ; if frequently 
applied, the tendency to ache may disappear altogether ; if 
the cord or periosteum be inflamed, little relief can be ex- 
pected from applications to 'the pulp. 

Eheumatism and gout are not unfrequently manifested in 
the jaws. The pain is dull; it may affect teeth that are 
sound, and commonly covers the space of several. It is not 
attended with suppuration, and is commonly coexistent with 
or immediately subsequent to a similar affection in other 
parts of the body. 

The pain of toothache is very severe, and from its location 
interferes very greatly with the convenience and business of 
life. It is therefore commonly borne with little patience, and 
prompt extraction is the common resource. When a tooth is 
so far carious that it cannot be saved by filling, it is usual to 
advise extraction, but it should be remembered that teeth 
will cease to ache long before they cease to be useful, and 
that even dilapidated molars often render more service than 
the best porcelain. Artificial teeth are expensive too, and 



308 AFFECTIONS OF THE MOUTH. 

most of those who apply to dentists to extract aching teeth, 
are unable to replace them with artificial substitutes. The 
loss of teeth with them involves not only permanent incon- 
venience, but deformity of visage. Dr. "Wood suggests, that 
"the occurrence of caries of the teeth sometimes appears to 
act as a derivative from the lungs, and to afford relief in pul- 
monary complaints. In such cases the teeth should be al- 
lowed to remain." We believe that in phthisis pulmonalis 
(pulmonary consumption,) no drain of pus, however small, 
can be dried up with safety. The hint of Dr. Wood is, there- 
fore, worthy of remembrance. 

Absorption of the Sockets. 

Absorption of the alveoli, accompanied by certain structu- 
ral changes of the teeth, is one of the common incidents to 
age, and is, therefore, not properly a pathological condition. 
It is one of the items in the general waste of a body obey- 
ing its natural law of decline. The necks of the teeth 
gradually become more and more exposed; they become 
loose, and fall out. The dentine having gradually become 
consolidated, the vitality of the teeth is impaired, and they 
become foreign bodies, and provoke the effort at removal, 
which is accomplished without inflammation and ulceration, 
because of the inability of the adjacent parts to institute 
these highly vital processes. This condition cannot be reme- 
died. 

Absorption of the sockets is, however, sometimes the con- 
sequence of active disease. In scurvy, mercurial saliva- 
tion, and gangrenous affections of the mouth, the alveoli are 
sometimes wasted and the foundations of the teeth destroyed. 
These diseases are the province of the general practitioner. 

"In one affection, the gums swell and assume a deep red 
colour, and the inflammation appears to be propagated into 
the alveoli, producing a thickening of the periosteum, and a 



AFFECTIONS OF THE MOUTH. 309 

consequent elevation of the tooth above its ordinary level. 
This condition is relieved after a short time, but again recurs ; 
and by its frequent returns' the tooth is lifted out of the 
socket, while the gum retreats from the neck, leaving por- 
tions of the roots exposed. The bony alveoli, thus in a cer- 
tain degree unoccupied, appear to undergo absorption; and 
the tooth, deprived of its support and separated by the ulce- 
ration of the gum from its soft connections, at length falls. 
The gum then heals, and the patient, who has usually 
suffered considerably during the progress of the affection, is 
restored to comfort. The disease commonly attacks a few 
teeth at once, commencing sometimes with the incisors, some- 
times with the molares; and though it occasionally produces 
only a partial loss of the teeth, in other cases, does not cease 
until it has destroyed the whole. It seldom occurs before 
the thirtieth year. It appears in some instances to result 
from long- continued mental trouble, and is said to especially 
affect women during pregnancy, and about the period of the 
cessation of the menses. Its causes, however, are not well 
known. The remedies indicated are those calculated to re- 
lieve inflammation of the gums, but they generally fail. " — 
{Wood's Pract. of Med) 

Jourdain described a condition which he called "conjoint 
suppuration of the gums and sockets," and various writers 
since Jourdain have verified his observations of it. 

It is evidently a constitutional rather than a local affection, 
though it tends to terminate by local processes. It is not 
uncommon, however, for local affections to owe their origin 
to general conditions, and yet to go through their course 
precisely as when occasioned by local causes. We have an 
instance in whitlow or bone felon, which is commonly the 
effect of local injury, but which certainly is sometimes de- 
pendent upon constitutional causes, for we have seen it occur 
successively on several fingers, and on both hands, while the 



310 AFFECTIONS OF THE MOUTH. 

patient was confined to his chamber, and no injury could 
have been produced by an external cause. The disease, 
however, pursued the same course, and terminated as readily 
and satisfactorily as though no constitutional disorder existed. 

The "conjoint suppuration," as a general rule, attacks the 
incisors first. It occurs more frequently in women, and at 
the time when decline of vigor begins to be observed. It 
comes on insidiously. At first nothing unusual is observed 
but a slight oozing of pus from behind the gums when they 
are pressed. Sometimes more manifest symptoms of conges- 
tion and inflammation are observed. The gums are swollen 
and soft, bleed readily, and manifest a disposition to true 
abscessive inflammation. Suppuration of the periosteum and 
the fang ensues. The whole socket becomes concerned in 
the destructive process. The teeth become painful, and are 
loosened. The socket is absorbed, and the teeth fall out. 
After the removal of the teeth the gams heal readily. 

The cause of the disease has been sought in the influence 
of bad atmosphere, depressing mental emotions, suppression 
of discharges, mercury, scrofula, syphilis, &c. Dr. Wood 
thinks it is sometimes an accompaniment of the phthisical 
constitution. In fact, it seems to be one of the many occa- 
sional indications of enfeebled vitality, incident to constitu- 
tional pravity, and its cure will, therefore, in any case depend 
to a considerable extent upon the success with which the 
general evil may be combated. 

In the commencement nitrate of silver ought to be tried 
upon the affected gum. The suppurating edge and separated 
portion should be touched with a pencil of the caustic. The 
stimulus may induce more healthy action. If, on the con- 
trary, the extent of suppurating surface be increased by the 
application, it will be vain to expect much from local medi- 
cation. M. Bourdet advises the application of the actual 



AFFECTIONS OF THE MOUTH. 311 

cautery, applied by means of a flat and delicate instrument 
inserted between the gum and tooth to the depth, of the de- 
struction of the socket. We have no faith in the advantage 
of this favorite Gallic application. If the lunar caustic fails, 
we have no hope in fire. It will be better to extract the 
teeth. 



CHAPTEE XYIL 

DISEASES OF THE LIPS. 

Hare-Lip. 

This is a congenital deformity, which consists in a fissure 
which divides the lip perpendicularly. Sometimes there are 
two fissures : the former is single, the latter double hare-lip. 

The cause of the deformity is unknown. It is a failure of 
nature, through an inscrutable cause, to complete the union 
of the two sides of the body at this part of the line of 
junction. 

Sometimes the affection exhibits a single slit, at others 
two, with a lobe or flap between them ; and sometimes the 
fissure extends along the roof of the mouth, the soft and 
hard palate being separated. Generally the lip on both 
sides of the fissure is not adherent to the alveolus, but some- 
times it is. 

Most commonly the upper lip only is affected, but some- 
times the lower is the seat of the fissure. When this is the 
case, the child cannot suck, or learn to speak with any dis- 
tinctness; adults suffer from the loss of the saliva, which 
runs freely from the mouth, and indigestion is the conse- 
quence. This form of hare-lip is seldom congenital, but is 
occasionally traumatic* or accidental. 

All degrees of hare-lip are attended with deformity and 
inconvenience, though some, from the extent of the separa- 

* Traumatic— the effect of a wound. 



DISEASES OF THE LIPS. 313 

tion of parts, are much more annoying and unsightly than 
others. Mr. Cooper describes a form of it, which must, how- 
ever, be rare, in which "the jaw is not only imperfectly ossi- 
fied in front, so that a cleft presents itself there, but one side 
of it projects forward,, and is at the same time inclined too 
much outward, drawing with it the corresponding part of 
the palate and the septum nasi, so that a very unsightly 
distortion of the nostril and nose is produced." 

When the fissure pervades the palate, the patient finds it 
very difficult to masticate or swallow, and articulation is 
necessarily very imperfect. 

It is obvious that surgical aid must be employed for the 
remedy of the deformity. 

A considerable difference of opinion exists among eminent 
surgeons as to the proper time for performing the operation, 
some advising to delay it until the child shall be four or five 
years old, and others preferring to operate upon the infant of 
months. 

Sir Astley Cooper used to narrate several cases in which 
a fatal termination resulted from too early an operation — 
convulsions having occurred from the pain and irritation of 
the wound. 

Undoubtedly, infants may often be operated upon with 
more facility than older children, and in some instances the 
deformity is attended with so much inconvenience as to au- 
thorize early operations. If, however, the child be able to 
nurse, and especially if it exhibit considerable nervous mo- 
bility, it will be better to delay the operation for several 
years. 

Mr. Liston advises to defer the operation until the first 
dentition shall have been completed. He says, " When the 
operation is undertaken at an earlier period, there is often 
great difficulty. Sometimes union does not take place, the 
parts turn out again, and the patient is rendered more de- 
21 



314 DISEASES OF THE LIPS. 

formed than in the first instance. When the features are 
enlarged somewhat, you have more ground to work upon ; 
you can put the parts neatly together, and you can almost 
answer positively for the union taking place." 

The cure depends upon the capability of two incised sur- 
faces to unite when brought into contact, and the proper 
performance of the operation consists in cutting off the edges 
of the fissure, and keeping the new surfaces so closely to- 
gether as to procure union by the first intention. 

The manner of performing the operation is sufficiently 
simple, yet it requires considerable dexterity to do it well. 

Some surgeons cut off the edges with a pair of strong 
sharp scissors; others place a piece of wood under the lip, 
and then pare off the edges with a knife ; others, confident 
in the correctness of their eye and the steadiness of their 
hand, place the child between their knees, with the head 
towards them, enter the knife into the lip above the angle of 
the fissure, and carry it downwards until it completes the re- 
moval of all the portion of the lip on that side which is re- 
quired. A similar cut upon the other side prepares the 
wound for closure. 

The bleeding readily stops upon pressure of the lips, and 
is rarely excessive. 

The wound is closed by the twisted suture: that is, two 
silver pins, with steel points, are introduced through the 
edges of the wound, penetrating the lip through about two 
thirds of its thickness, the first near the inferior extremity 
of the wound, and the second a quarter of an inch above. 
The divided surfaces being thus brought into contact, thread 
is wound repeatedly around the pins, first transversely, and 
then obliquely, from the right side of the upper to the left 
of the lower, and vice versa, until the contact is firmly se- 
cured. The points of the pins should then be unscrewed, 
and a dossil of lint placed under each end of them. The 
pins should be somewhat curved and flattened. 



DISEASES OF THE LIPS. 315 

Different bandages have been devised for the purpose of 
supporting the pins and preventing the separation of the 
adapted surfaces. That recommended by Mr. S. Cooper is 
used as follows : A close strong night-cap is provided, with 
a piece of broad tape attached to the back part of it, and 
with two ends of sufficient and equal length. A compress 
is then to be laid over one cheek, and fitted by bringing one 
portion of the tape forward over it, which is to be fastened 
to the cap on the opposite side of the head. The other 
compress is then to be applied and fixed in a similar manner. 
Lastly, a bandage is to be put under the chin, and brought 
over each compress up to the top of the head, where the 
ends of it are to be fastened to the cap. During all these pro- 
ceedings, until the compresses are well secured, the assistant 
must support them steadily with his hands. Lastly, the 
bandage, compresses and cap should all be securely stitched 
together. 

The cut through the lip must be as straight and clear as 
possible, and the operator need not fear to take sufficient of 
the edge to ensure such a surface as will be well coapted. 

When the hare-lip is double, the older surgeons advised 
to perform the operation on one side and then upon the 
other, but this is unnecessary. The edges may be prepared 
at once, and the needles pushed entirely across through the 
intermediate flap. Sometimes a piece of bone projects and 
pushes out the flap. If so, the bony projection must be 
either reduced by compression or cut off. It is always im- 
portant to save the alveolus, and it appears from the practice 
of Desault and Mr. Dunn, that it is seldom necessary to re- 
move it. 

Mr. E. Woakes, Jr., suggests that instead of using the ordi- 
nary hare-lip pins, it is a better plan to pass silver wire 
through the parts, fastening the projecting ends by small 
perforated splints. The edges may be brought together 



316 DISEASES OF THE LIPS. 

much more accurately, and the scar is less. (See Braith- 
waites Retrospect; part 42, page 163.) 

There is often a deficiency of bone, which will cause de- 
formity after the hare-lip has been successfully treated. 

Yery often, when the fissure extends along the palate, it 
will be approximated after the closure of the lip ; but this 
is not always the case, and articulation and mastication con- 
tinue to be very much interfered with by this unfortunate 
cleft of the palate. 

The dentist can often remedy this serious deformity, by 
nicely adapting a gold plate, so as to form a solid artificial 
palate, which will tolerably well supply the want of the 
natural one ; and this may be considered the most available 
means of relief at our disposal. 

Operations have frequently been performed for the cure of 
this palatine fissure, and sometimes have succeeded. The 
operation, however, is difficult, very painful, considerably 
dangerous, and very, uncertain, and should never be per- 
formed except by a dexterous and experienced surgeon, and 
under circumstances in which no artificial means could be 
used to cover the cleft. The design of the operation is pre- 
cisely the same as in the case of that for hare-lip, viz. to cut 
off the edges of the fissure and unite them by sutures so as 
to procure union. 

The lips being very vascular, abundantly supplied with 
muscles, mucous glands and nerves, are liable to become the 
seat of ulcers and tumors of various kinds. In the male, 
carcinoma of the lip is perhaps more frequently met with 
than it is in any other part of the body. 

It is not necessary to particularize these affections, nor to 
give a detailed account of their phenomena and treatment. 
They must of course be managed as similar conditions else- 
where, the treatment being modified to suit the exigencies of 



DISEASES OF THE LIPS. 317 

the particular case, and the peculiarities of the location. All 
operations upon these organs must he conducted with great 
carefulness and nicety, on account of their sensitiveness and 
vascularity, and of the deformity and serious inconvenience 
attending any permanent alteration of their relations or 
structure. Of these, adhesion to the gums and contraction of the 
lips are the most common and most serious. 

Adhesion is the result of acute inflammation of the surface 
membrane of the lip and gum, in the course of which 
plastic lymph is thrown out, and becoming organized, forms 
a permanent bond of union between the parts. In all cases 
of abrasion of these surfaces, or of long continued inflamma- 
tion, care should be taken to prevent this accident. It can 
rarely happen, unless the parts thus prepared to unite be 
pressed together by a bandage or some similar mechanical 
application. 

I have seen it, however, result from salivation of a very 
severe grade. The cheek, from its less mobility, is more 
liable to this accident than the lips. 

Contraction of the mouth may result from a burn, as may 
also adhesion of the lips to the gums. 

When so serious a deformity has occurred, it can only be 
remedied by an ingenious operation, which, though very 
painful, is generally endured with cheerfulness, so terrible is 
the sense of deformity to most persons, especially to females. 

A few cases will be sufficient to show what has been, and 
what may be done, in unfortunate cases of this kind, and 
will furnish to the ready mind a number of valuable sug- 
gestions. 

Simple dilatation of the mouth will be unsuccessful, and 
incision at the commissures will be ineffectual in permanently 
enlarging the orifice, on account of the impracticability of 
preventing reunion between the severed portions of the skin. 

In order to obviate this difficulty, the celebrated Dieffen- 



318 DISEASES OF THE LIPS. 

bach suggested that a strip of mucous membrane should be 
folded over the edge of the incision. This fortunate thought 
has led to a number of brilliant and successful operations 
for the cure of this class of deformities. The following 
cases are specimens: 

M. H., aged twenty -two, admitted to the hospital under 
Mr. Liston. About a year before, she was knocked down in 
a brawl, and a man jumped upon her, lacerating and bruising 
her cheek and mouth very extensively, and fracturing her 
jaw. She went to St. Thomas' Hospital, where her jaw was 
put up and bandaged. These were not removed for some 
time, and when taken off, the wound on the right side of 
the mouth was found to be healed, and the cicatrix consider- 
ably contracted. Since then the contraction has continued 
somewhat, and now the mouth is so small that she can 
scarcely get any solid food to pass her lips. There is a large 
and dense white cicatrix on the right side of the mouth, 
rather sharp and puckered toward the angle. 

Mr. Liston removed a triangular portion of the cicatrix 
on the right side of the mouth, dissecting it off the mucous 
membrane, which was then divided to the extent of the 
external wound. Lint, dipped in cold water, was then laid 
over the surface, to suppress the oozing of blood, which was 
by no means considerable. About five hours after the ope- 
ration, all oozing having ceased, the mucous membrane was 
turned over the cut edge of the cicatrix, and united by three 
or four points of suture to the skin of the cheek ; by this 
means, a mucous surface was secured to the newly formed 
prolabium, and the gradual cicatrization and consequent 
contraction avoided. On the day after the operation, there 
was a little swelling around the wound, not much pain, and 
in ten days afterwards the patient was discharged much 
relieved. 

Case II. — The daughter of a highly respectable phy- 



DISEASES OF THE LIPS. 319 

sician, when she was eleven years old, was accidentally 
thrust against a heated stove, and her hands, arms, neck and 
the lower part of her face severely burned. 

In spite of all the judicious means employed by the fa- 
ther, the wounds about the mouth healed with so much 
contraction that the opening into that cavity was almost 
obliterated. Her father then endeavored to distend her 
mouth by tents, but these accomplished nothing. He then 
endeavored to enlarge the orifice, by making a horizontal in- 
cision from each angle of the mouth, and preventing the 
surfaces from uniting, by the interposition of tents ; but this 
expedient failed also. 

The patient was then brought to Dr. Mutter, who says : 
" When I first saw her, nearly a year had elapsed since the 
occurrence of the accident. Her appearance at this time 
was very singular. Firm and dense cicatrices nearly sur- 
rounded the mouth, but were most marked on the lower lip 
and about the angles; while the orifice of this cavity was 
barely large enough to admit the point of the finger, and 
presented an oval form. The cicatrices of the incision made 
by her father were also very apparent at each angle. The 
general health was good." 

Dr. Mutter performed upon this young lady the operation 
as proposed by Dieffenbach. 

" The patient was seated in a low chair, with her head sup- 
ported by her father, and exposed to a good light. I then 
introduced the extremity of the fore-finger of my left hand 
into the mouth, and placed it under the left labial angle, 
which by this means was rendered prominent and sufficiently 
firm to permit the second step of the operation to be readily 
executed. 

"This is accomplished by the introduction of one blade 
of a pair of narrow straight scissors into the substance of 
the cheek, between the mucous membrane and the other 



320 DISEASES OF THE LIPS. 

tissues, and a little above the commissure. The blade is 
then slowly pushed from before backwards, separating, as it 
passes along, the mucous membrane from the muscles and 
integuments, until its point reaches the spot at which we 
wish to locate the new angle of the lips. The blades are 
then closed, and the parts included between them cut squarely 
and smoothly at a single stroke. The first incision being 
completed, the scissors were withdrawn, and a second one 
parallel and similar to the first, made in the lower lip, the 
distance between the two being about three lines. These 
incisions were then united at their posterior termination by 
a small crescentic section. 

"By these cuts it is evident that a small strip of muscle 
and integument was insulated from the surrounding parts, 
and it only remained to separate it from the buccal mucous 
membrane, which was easily done by a single stroke of the 
scissors. 

" The second step of the operation being thus finished on 
the left side, similar incisions were performed on the right. 

" The next steps of the operation, and by far the most diffi- 
cult of the whole, were the division into equal portions, of 
the mucous membrane, the eversion of the flaps, and their 
attachment to the edges of the incisions just made, as well 
as to the red pellicle of each margin of the lips. 

"To divide the mucous membrane equally, I separated 
the jaws of the child as much as possible, by which measure 
the membrane was put upon the stretch, and kept sufficient- 
ly firm to bear the operation of the scissors. The incisions 
in the membrane did not extend as far as those made in the 
muscles and skin, but stopped short about three lines from 
the union of the latter. This was done in order to make the 
outer portion of this tissue adapt itself accurately to the new 
commissure. The flaps were then brought out, reflected 
over the margins of the wounds and firmly attached to them 



DISEASES OF THE LIPS. • 321 

by means of the twisted suture, the needles used being very 
short and fine. The membrane must be first attached to 
the commissure, by which measure we secure the proper 
adaptation of the flaps to the other parts. 

"Everything being thus properly adjusted, a common roller 
bandage was applied, as in cases of fracture of the lower jaw, 
in order to prevent any derangement of the wounds. The pa- 
tient was then placed in bed, with her head elevated, and as 
she had, just before the operation, eaten freely of some light 
food, ordered to take no nourishment of any kind until the 
next visit, and to be perfectly silent. 

Four days after the operation the bandage was removed, 
and the Dr. proceeds : " The sutures, which had been closely 
bound down to the parts by blood, were carefully softened 
with warm water and cut away. As soon as they were re- 
moved the most gratifying exhibition of the success of the ope- 
ration was afforded. On both sides, union between the evert- 
ed mucous membrane and the margins of the wounds had 
taken place nearly throughout, and the new lips presented an 
appearance almost natural. Some of the needles were then 
removed, but as there appeared to be a feebleness in the ad- 
hesions at some points, the needles passing through them 
were allowed to remain, and a thread cast loosely around 
them. The bandage around the head was also reapplied. 

"Nothing i emarkable occurred in the subsequent treatment. 
The dressings were taken off in eighteen days. The mouth 
presented a very good appearance, though the lips were 
somewhat thinner than natural, and there was some difficulty 
in bringing them into close contact, especially at the central 
portions. I have no doubt, however, but that this defect will 
soon disappear. 

An operation of a similar kind, but much more difficult, 
performed by Dr. Hullihen, will be described in a subsequent 
chapter. 



CHAPTER XVIII. 

DISEASES OF THE GLANDS AND GLAND-DUCTS. 

Salivary Tumors. 

Banula* — This is the name given to a tumor under the 
tongue, which is caused by obstruction of the ducts of the 
sublingual gland, and the detention of secretion which con- 
sequently results. 

This swelling is not usually very large, though sufficiently 
so to cause great inconvenience ; but occasionally it has been 
observed of an enormous size. Le Clerc mentions a case in 
which the tumor filled the whole mouth, and pushed forward 
the teeth of both jaws. The patient was nearly suffocated, 
and must have died had he not been relieved by an opera- 
tion. 

The case related by Boinet to the French Academy, was 
even worse. The swelling not only filled the whole mouth, 
but projected out of it for a considerable distance. The two 
upper incisor teeth on the left side, were lodged in a depres- 
sion observable there, and the canine teeth of the same side, 
forced outwards by the mass of the disease, had pierced the 
lip near the commissure. A fluid, resembling mucu s, flowed 
from a narrow aperture at the lower part of the swelling. 
The tongue could not be seen, so much was it pushed back- 
wards, and for some time the patient had subsisted only upon 
liquid food, which he was first obliged to convey to the back 
of his throat by some mechanical contrivance. The four in- 

* Rana — a frog; so called from a fancied resemblance. 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 323 

cisor teeth, two canines and first molars of the lower jaw had 
been pushed out of their sockets by the pressure of the swell- 
ing. The patient's aspect was alarming, and he was threat- 
ened with suffocation. 

Extirpation was thought necessary, and it was performed 
with all due caution. The large cavity thus occasioned was 
filled with lint. The lower jaw being diseased, Boinet 
scraped some of its surface off, and covered the places with 
lint, either dry or dipped in spirits of wine. Some exfolia- 
tions followed, and the fungous granulations which grew, 
were suppressed with proper applications. In three months 
the cure was completed* 

Eanula may readily be detected. It presents itself in the 
form of a rounded or oval, soft, semi-transparent tumor, on 
one or both sides of the frenum linguae. It is not painful, 
and occasions little inconvenience until its volume becomes 
sufficiently great to interfere with the movements of the 
tongue. 

Nevertheless, encysted tumors of various kinds do some- 
times occur in this locality, and have frequently been mis- 
taken for ranula. 

Simply to open the tumor and let out the fluid contents, 
will not cure the disease, inasmuch as the obstruction of the 
ducts will continue. It becomes necessary, therefore, to re- 
open these, or, if this cannot be done, to make an artificial 
opening, which may permit the secretion of the gland to 
escape. 

Lewis advised the introduction of small leaden stilets to 
dilate the canal, and permitting them to remain for a clay or 
two at a time. Dr. Physick and others preferred the passage 
of a thread through the tumor, which was permitted to re- 
main as a seton. Dr. Eeese considers this plan infallible, or 
nearly so. 

* Cooper's Surg. Diet. Art. Eanula. 



324 DISEASES OF THE GLANDS AND GLAND-DUCTS, 

The method pursued by Lewis, and followed by Dr. Mut- 
ter, is to make an oval or round incision, and then to touch 
the margin with nitrate of silver, so as to create an artificial 
fistula. 

Sometimes all other means fail, and it is necessary to dis- 
sect out the whole tumid mass. 

The salivary glands are sometimes the seat of tumors of a 
more formidable character. Being enclosed, the sublingual 
gland especially, by the muscles of the throat and tongue, 
these tumors, even if suppuration takes place, cannot com- 
monly be relieved by the discharge of the contained matter. 
The sac may be repeatedly punctured without relief, for the 
fluid continues to form, and repeated wounds result in thick- 
ening and enlargement of the gland, and finally a solid tu- 
mor is formed, which may go on to enlarge until it may 
cause suffocation. 

The case of Margaret Murray, so graphically related by 
Mr. John Bell, should warn us against trifling with even 
apparently trivial tumors of these parts, and dentists, as they 
may be the first to observe, should be prepared to distin- 
guish these swellings, and advise that prompt and decided 
treatment which is so important in these cases. In the case 
of Margaret Murray, the tumor was as large as the patient's 
head, and threatened imminent suffocation. In fact, the poor 
woman lived in a state of semi-strangulation. When upon 
the verge of gangrene, the tumor, which was hard upon the 
surface, but fluctuating beneath, was transfixed with a trocar. 
About two pounds of thick ropy matter were discharged. It 
was hoped that this discharge would afford relief; but, as 
Mr. Bell very justly observes, those who indulged such an 
expectation did not recollect that to produce a secretion so 
profuse, a great mass of vascular substance is required, and 
the consequence of permitting a gelatinous collection of mat- 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 325 

ter to attain to such a size is, that the vessel by which it is 
secreted, not being, as in a case of suppuration, ulcerated 
or destroyed, the basis, consisting of these vessels, is consoli 
dated into a tumor. The sac may be emptied, but the nu- 
cleus to the sac cannot be discussed, but hardens and inflames 
pari passu with the evacuations. 

In the case of this poor woman, though the salivary mat- 
ter continued to run, thin and pellucid, through the open- 
ing, the tumor did not diminish. " She lay reclined, always 
struggling for breath, and sometimes attacked with violent 
asthmatic paroxysms; the jaws almost entirely closed, the 
mouth continually open; the nostrils dilated, and the stupor, 
which such difficulty of breathing causes, increasing every 
moment; and her swallowing being equally difficult with 
her breathing, she expired in the fourth week." 

Although tumors of this kind may contain thin matter, a 
mere puncture is not sufficient for their relief. A free inci- 
sion must be made, laying open the diseased gland, and the 
treatment directed to the permanent adhesion of the walls of 
the sac. The sooner this is done the better. 

Tumors of the Submaxillary Gland. 

This gland is very subject to inflammatory swellings, 
which frequently become indolent, and remain for a long- 
time without causing inconvenience. Occasionally, however, 
it is the seat of very dangerous and even fatal tumors. 

Mr. John Bell records the case of " Jenny Brown, a poor, 
solitary thing, who worked laboriously to maintain her aged 
mother, her father being for some years dead. She slaved 
at all kinds of work, as an out-servant in a farm yard. Af- 
ter churning milk, being exceedingly heated, she went out 
with her cap loose and her jaws exposed, and by carrying 
bundles of wet grass for the cows upon her head, had a se- 
vere tooth- ache, for which a tooth was pulled ; and still con- 



326 DISEASES OF THE GLANDS AND GLAND- DUCTS. 

tirming in the same labor ; she got cold. Thence arose a ker- 
nel-like swelling of a gland nnder the lower jaw, near the 
gum of the corrupted tooth. Her face was swelled so that 
her e yes were closed ; the lump grew as big as a hen's egg, 
with severe pain; the swelling of the face subsided, the pain 
ceased, but the glandular tumor remained. Such was the 
slight beginning of the disease." The tumor, however, con- 
tinued to enlarge until it became necessary to extirpate it. 
This was attemped in an awkward and irresolute way, and 
abandoned in the midst of the operation. " One advantage this 
poor creature derived from this unsuccessful operation, viz. : 
the relief from pain, for she was relieved by the loss of blood, 
insomuch that she recovered her health, and in some degree 
her strength, and returned to work for the support of her old 
mother : at least, she could spin. For a long time she has 
been unequal even to this. She has lingered and wasted in 
a very helpless condition, and is now in a state of extreme 
weakness from want of food. She walks but a few paces 
without stopping for want of breath ; her swallowing is diffi- 
cult ; she has great pain, night and day, from the mere dis- 
tention and size of the tumor. The weight of it is intolera- 
ble, and it appears to me that in not many weeks she must 
be relieved from her sufferings." 

The suffering of the patient seemed to be occasioned by the 
great bulk of the tumor pressing upon the trachea, and even 
the breast, and embarrassing respiration. The tumor had 
every character of what is usually called a wen ; the whole 
mass incredibly heavy in proportion to its bulk, so that she 
supported it continually with a sling round the head and 
neck. It was extremely firm, not very vascular throughout 
its substance, but receiving its arteries at particular points. 
It had no great veins running over its surface, whence Mr. 
Bell presumed that it had nothing of a cancerous character 
or irritated circulation. 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 327 

Mr. Bell wished to operate, but was over-ruled. 

Some remarks of Mr. Bell, in lecturing on these subjects, 
are so judicious, that I cannot refrain from quoting his lan- 
guage at some length. 

"But it is not the discussion of interesting doubts and ques- 
tions of life and death, nor the performing operations within 
the limits of possible success or possible* safety, that consti- 
tute the chief occupation of one engaged in practice. The 
more homely talent of distinguishing the various aspects and 
characters of tumors, and treating them judiciously, is far 
more desirable to acquire; and, indeed, there is a very per- 
plexing variety of tumors within the mouth and around the 
jaws, which one learns to distinguish only by referring their 
various aspects to corresponding peculiarities in the structure 
of the parts. The tumors which I have just described are of 
a very malignant character, and I confess I know not whether 
to refer them to the salivary or the lymphatic glands ; to the 
latter, rather, I believe. This, for example, of Mr. M., though 
it looks like a tumor of the submaxillary gland, which holds 
imbedded, I may say, in its substance, the facial artery, it 
could not have been extirpated without dividing that artery. 
The submaxillary gland is divided into two masses, and the 
trunk of this artery is received into the recess or cleft. The 
artery seems to twist round the gland, and I have, both in 
extirpating the submaxillary gland and in assisting at such 
operations, recognised it by this mark. 

" The following case, if not full of interesting particulars, 
is at least accompanied with useful rules, and I transcribe 
them from my case- book, with those reflections which arose 
in my mind when forming my opinion and preparing for the 
operation, as I have ever done, with a scrupulous and con- 
scientious desire to foresee every eventual danger, and re- 
collect every circumstance, anatomical or pathological, which 
might contribute to my patient's good; the reflections, you 



328 DISEASES OF THE GLANDS AND GLAND-DUCTS. 

will perceive, have a mutual relation to the instruction of my 
pupils and my own improvement. 

"It is the case of a young lady, who came from a very 
great distance, urged by her own fears and the persuasion of 
her surgeon. 

"First, I observed that the gland affected, seems to be the 
very gland which, after an unsuccessful operation, grew to so 
immense a size in the case of Jenny Brown, and in her, though 
the tumor arose from the slightest and most accidental cause, 
(extraction of a tooth,) without any cancerous diathesis, or 
other malignant tendency, it proved fatal by suffocation. 
What might have become of this lady, it is easy to foresee, 
had she not been warned by her surgeon, and alarmed by the 
recent accession of pain for her own safety. 

"Secondly, when we are consulted what is to be done in 
any particular case, we are, in other terms, called on to prog- 
nosticate what will be the patient's condition at the distance 
of one or two years. In the present case, the gland is very 
large, and of a stony hardness. It never can suppurate; it 
is even threatened with a cancerous inflammation ; it is indeed 
incapable of any other. The pain requires that something 
should be done, and our prognostics may be safety grounded 
on this unquestionable assumption, that such a tumor will 
not fail to grow, and that, in one or two years, the deformity 
and bulk will of itself be a motive, while the suffocating con- 
dition of the patient will be an absolute reason for operating, 
however dangerous the operation may be rendered by such 
unwise delay. It is moreover to be observed, that this gland 
is the submaxillary gland, which has the facial artery niched 
in between its two lobes, not so inextricably, indeed, as the 
parotid is connected with the carotid artery, but in a degree 
to give trouble to the surgeon, and accompanied with a de- 
gree of danger, in the case of operation, which is well worth 
calculating. 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 329 

"Thirdly, we are to -regard tlie actual circumstances of 
every patient as a part of his case, and the danger to this 
lady, if remanded to her own country, so far distant and so 
difficult of access, is but too palpable. Should we speak to 
her the usual temporizing language, and say, 'It will perhaps 
get well ; a slight course of mercury or cicuta may be useful, 
and time may do much ; perhaps it may be well to wait;' it 
may happen that the gland may become stationary in its 
growth. A mercurial course may be of use, but I fear that 
this is, in the truest sense, tampering with a tumor, and that 
time can do nothing but increase the danger. 

" It seems to me but too possible that this lady, before she 
can take a second resolution and accomplish a second journey, 
will be suffocating and in immediate danger of death. Then 
we should not venture to do that operation which is now com- 
paratively easy ; for this gland being seated in the angle be- 
twixt the trunk of the carotid artery and its first great branch, 
the maxillary or facial, will distend that angle, and both the 
trunk and its branch will be too closely united with the tu- 
mor to admit of operation, or will make the operation most 
dangerous and critical. 

"Fourthly, though there is no imminent danger in the pro- 
posed operation, the circumstances are sufficiently forbidding 
to make it far from being a matter of choice. My assistant 
was unwilling that it should be performed without the advice 
of Dr. Munroe, and his assent seemed rather reluctant. The 
tumor is of a very considerable size ; it is plainly the sub- 
maxillary gland, as may be inferred from its shape, size and 
peculiar hardness ; not a lymphatic gland, for then, most like- 
ly, more than one would be enlarged. We must be resolved 
to deal with the artery in one of two ways : either to dissect 
it so from the tumor as to insulate the artery, and turn the 
tumor from under it ; or, should this attempt threaten to em- 
barrass our operation, to cut it across where it lies over the 
22 



330 DISEASES OF THE GLANDS AND GLAND-DUCTS. 

middle of the tumor, tying before dividing it, lest it should 
shrink back towards its trunk. ]STo one circumstance is so 
favorable to the operation as that extreme hardness of the tu- 
mor which makes the operation necessary ; for that shows it 
to be circumscribed, and to be little connected by inflammation 
with the cellular substance. 

" Notes of the Operation. 

" "We had agreed either to dissect so as to lay the artery 
on one side while employed in extirpating the gland, or to 
tie and cut across, and so proceed with greater freedom in the 
more dangerous part of the dissection ; but after the first in- 
cision, which I made according to the length of the jaw-bone, 
the incision being long and more free, the several parts ap- 
peared in so advantageous a state as to leave no doubt nor 
difficulty in the rest of our proceedings. 

"The artery presented itself arching over the diseased 
gland, much elongated and serpentine, so that in place of em- 
barrassing the operation with any needless delicacy, or endan- 
gering the shrinking up of such an artery towards its trunk, 
we passed two ligatures of single thread under it, cut betwixt 
the ligatures, and then proceeded more confidently in extir- 
pating the gland. There we found no such adhesion of it to 
the trunk, or rather to the sheath of the carotid, as we had 
reason to apprehend. The tumor was of such a stony hard- 
ness, the cellular substance so loose, the arteries so disen- 
gaged from it, that without the help of the knife, with only 
the swallow-tailed end of its handle, which I used as a scalpel, 
I turned out the tumor in a few seconds, and the tumor carry- 
ing its cellular substance along with it, the styloid muscles 
were left as clear, distinct and bare as after a neat dissection 
upon the dead subject. 

" Case II* — A young woman of Berwick, whose native 
peculiarity of accent had got a singular aggravation by such 

* Principles of Surgery, by John Bell, edited by Charles Bell. 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 331 

an uncouth obliquity and imperfect motion of the tongue, as 
conveyed the notion of her attempting to chew and turn each 
vocable with her tongue before she proceeded to swallow it, 
in place of uttering it. 

* This was produced by a tumor of very great size, and of 
an appearance so peculiar as plainly to denote its character. 
It consisted in a vast collection of matter in the sublingual 
gland, and as that gland is covered by the whole thickness 
of the tongue within, and by the mylo-hyoidcei muscles 
without, and bounded by the line of the jaw-bone, it had the 
following singularities of character : It could not be distin- 
guished as a tumor, but had rather the appearance of a 
general swelling of the lower part of the face, jaw and neck, 
such as often accompanies severe tooth-ache or mumps. 
Upon laying the hand upon the outside of the neck, below 
the lower jaw-bone, the whole hand was filled with a swelling, 
apparently solid, but so little convex or circumscribed as to 
resemble in no degree the tumor of any particular gland, and 
yet so limited and so firm as not at all to resemble the general 
tumefaction proceeding from tooth-ache. Upon introducing 
the finger into the mouth, you found the tongue raised, turned 
edge uppermost, and pressed entirely towards the left side 
of the mouth, the external tumor being upon the right side. 
Upon pressing the fingers very firmly down by the side of 
the tongue, and reaching from without, you could sensibly 
perceive not so properly a fluctuation as an elasticity, — which 
implied the presence of a fluid ; the tumor seemed elastic like 
a foot-ball, but with a degree of tension which made it seem 
almost solid. It was by comparing a variety of circum- 
stances, especially the original place and slow growth of the 
tumor, that I confidently referred it to the sublingual gland. 
In this I had the advantage of the surgeon under whose 
particular care she was, but I did him the justice to send her 
back to him again and again, expressing my opinion and my 



332 DISEASES OF THE GLANDS AND GLAND- DUCTS. 

wish at the same time, that he should do whatever he might 
suppose right. By good fortune, she called upon me the 
day she was to return home, nothing being as yet done to 
the tumor, but supplied with abundance of blisters and 
plasters to apply at a fit opportunity to her throat. I felt 
now that professional ceremonies should give way to essen- 
tial charities. I placed her in a chair, and almost without 
her consciousness, at least before she was aware, I struck a 
fine bleeding lancet deep into the tumor by the side of the 
frenum of the tongue, when, from the firm compression of 
the surrounding parts, the matter, though too gross to pass 
freely through such an opening, was spewed out from the 
orifice, in a manner expressly resembling that in which yel- 
low paint is squeezed out from the bladder upon a painter's 
pallet. It was of a deep saffron color, thicker than mustard, 
mixed like gruel with seed-like particles, and exceedingly 
fetid. I knew that the tumor was not emptied, though the 
outward swelling was almost gone, but I also knew that 
though I should not enlarge the opening, the second secre- 
tion from the surface of the sac, which is in all cases thin, 
would dilute and wash out whatever viscid matter remained ; 
and when she saw how suddenly my prognostic was fulfilled, 
she expressed a perfect confidence in whatever I predicted, 
and a perfect willingness to submit cheerfully to whatever 
I proposed to do. Next day I introduced the point of a 
probe-pointed bistoury into the orifice made by the lancet, 
and knowing that the lingual artery lies on a lower level, 
imbedded among the muscles, and running along the lower 
surface of the tumor, while I had over the point and blade 
of my bistoury nothing but the inside membrane of the 
mouth, much thickened, I ran it fearlessly and at one stroke, 
as the less painful way, along the whole length of the tumor, 
when the thickest of the yellow mucus flowed freely or was 
raked out with the points of the fingers and the handle of 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 333 

the bistoury ; and the tongue, descended now to its natural 
level, was in a capacity once more of delivering the peculiar 
dialect of her native city in all its purity. 

" So tense and apparently solid was this tumor, in conse- 
quence of the compression by so many surrounding muscles, 
that her surgeon mistook it for a solid and strumous swelling. 
I reckoned that in this, as in all cases of sacculated tumor, 
the second secretion, which was thinner, would wash out the 
thicker mucus, and I was not deceived; but she left me too 
early for me to witness the obliteration of the sac. 

"I find it, in all such cases, a matter of some importance, 
especially in a girl, to anticipate the outward suppuration of 
any sacculated tumor, by puncturing it, though to a great 
depth within the mouth and under the tongue, and equally 
necessary to be at pains in preserving the opening and ob- 
literating the sac ; a slight misconduct in this respect occa- 
sions much distress to the patient, and much superfluous la- 
bor to the surgeon. Among the examples of this which I 
have had occasion to remark, the following is the most in- 
structive. 

'• Case III. — The case of Peggy Hall represents a tumor, 
which in all its stages, and for a course of three years, was 
ill understood and worse treated. She was a stout and lusty 
girl, about twenty-two years of age. The tumor occupied 
all the left side of the neck, from the lobe of the ear and an- 
gle of the jaw, quite to the sternum, displacing the mastoid 
muscle. This, like the tumor of Jenny Brown, arose from 
that slight inflammation which follows the extraction of a 
tooth. More than two years ago, after being distracted with 
tooth- ache, she had two carious teeth pulled from the lower 
jaw, and she distinctly remembers that two days after the 
extraction of the sound tooth she was sensible, upon undo- 
ing the flannels in which her swollen and inflamed face had 
been for some time wrapped up, that there was a little lump 



334 DISEASES OF THE GLANDS AND GLAND-DUCTS. 

about the size of a small plum. It lay under the angle of 
the jaw, and had never ceased to grow, and has now, without 
the slightest pain or change of color, attained the present 
size. In the month of April, 1799, she was directed to apply 
some kind of plaster. In May, Dr. Monroe advised her to have 
it opened. In a few weeks after this was attempted by the 
surgeon of the village in which she lived, who made a large 
incision, but being soon alarmed, he laid aside the knife and 
lancet, and prosecuted his work rather by boring than by 
cutting. He tried, with probes and directors, to make good 
his way into the sac, but having pushed them very deep, 
and toiled for half an hour in vain, he abandoned his purpose. 
" The tumor was distinctly a great sac of fluid secretion. 
There was nothing doubtful in the case. The sac lies under 
the platysma myoides, and under and before the mastoid 
muscle. The belly of the mastoid being raised upon the 
bag or tumor, feels soft and flaccid, and might have seemed 
to an unskilful surgeon to form a part of the tumor. By 
making his incisions over the belly of the muscle, he could 
not penetrate to the sac otherwise than through the body of 
the mastoid muscle. Having cut to a considerable depth 
among solid and quivering flesh, he became alarmed. "Will- 
ing still to penetrate farther, and yet without danger, he 
bored with his finger, cut a little obliquely with his knife, 
and bored a little more with his directory, till, having buried 
it apparently in the tumor, to the depth of three or four 
inches, he believed, and to the ignorant relatives and patient 
seemed to prove, that there was no fluid in the tumor, while 
in all this there was nothing singular but his own awkward- 
ness. He had penetrated entirely under the belly of the mas- 
toid muscle, pushing his probes obliquely between it and the 
sac. To avoid the great vessels of the neck, he wrought 
obliquely backwards, and by cutting obliquely backwards, he 
made good his way under the belly of the mastoid muscle. 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 335 

" The young woman endured the disappointment and suf- 
fered the tumor still to extend, not without great inconveni- 
ence and deformity, for seven or eight months, the operation 
being then performed more correctly and confidently. Every 
circumstance tended to confirm the notions I had formed of 
this awkward proceeding. The surgeon who now operated 
was timid and careless in conducting the cure. 

" The incision through the skin only was freely made. 
The incisions through the platysma myoides were made ti- 
midly, the flesh of its fibres retracting and quivering as they 
were cut. The sac then burst from betwixt the divided fibres 
of the muscle, white and transparent. Upon this being di- 
vided, several pounds of thin serous" HitiE gushed out. Then 
the long iron probe was passed along the cavity of the tumor, 
and its point cut upon at the anterior edge of the mastoid 
muscle; in short, near the place of the former incisions; 
whereas, to lie across the tumor, the point should have been 
cut out behind the belly of the mastoid, and then the seton 
or cord would have more effectually inflamed the sac and ob- 
literated the cavity. 

" But this girl was doomed still to suffer from timid prac- 
tice. The seton, ill-introduced at first, was worse managed. 
In whatever way introduced, it should have been made to 
obliterate the sac. The sac was permitted to remain always 
half full ; its walls were never brought together so as to fa- 
vor their adhesion; the cord was even withdrawn and the 
orifice permitted to heal ; the fluid again collected to the 
amount of two pounds ; it was again evacuated by freeing 
the old opening, slitting up a part of the muscular sac with 
a probe bistoury, and obliterating it, (a purpose which was 
very slowly accomplished,) by strong injections of port wine 
and stimulating medicines. 

" The case of this girl, which was protracted by unskilful 
treatment to six months, should have been accomplished in 



336 DISEASES OF THE GLANDS AND GLAND-DUCTS. 

three weeks, and while the sac was pouring out matter from 
its thickened walls, and hardening into a solid tumor under 
the jaw, the girl was in danger of having established an in- 
curable and growing disease; for a tumor so situated, and 
proceeding from such a cause, could never, by the most dex- 
terous operator, have been dissected away from the neck and 
jaws." 

I have felt no hesitation in quoting at length the preceding 
narratives of cases, and the excellent remarks attending them. 
Facts like these impress the mind of the reader much more 
forcibly and permanently than dogmas. In the instances 
above cited, we see what serious consequences to the glands 
of the mouth may be occasioned by the operation, to which 
every man thinks himself competent — the extraction of a 
tooth ; and we also see how very important it is to be able 
to detect the nature of the disease in its earliest manifestation, 
and to apply the bold prompt remedy which only can pre- 
vent the threatened mischief. 

Certainly, if the dentist, however careful, may be the un- 
fortunate agent to produce such tumors, he ought at least to 
be prepared to do all that skill can do to remove them. 

Tumors of the Parotid Glands. 

The parotid is the greatest of the salivary glands, and fur- 
nishes the largest part of the saliva. It is situated in the ir- 
regular cavity bounded by the ramus of the lower jaw and 
the mastoid process of the temporal bone, penetrating as 
deeply back as the styloid process, and even dipping behind 
it. It extends from the zygoma to the angle of the jaw, and 
from the meatus externus and mastoid process to the masse- 
ter muscle. This gland is subject to ordinary inflammatory 
swelling from cold, and especially to a peculiar, specific in- 
flammation called cynanche parotidea, or vulgarly, mumps. 

The parotid is also sometimes the seat of carcinomatous 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 337 

disease, and may be affected by all the modes of disorganiza- 
tion which affect glandular structures. 

The position of this gland, and its vascular and nervous 
connections, render its extirpation one of the most difficult 
operations in surgery. Until recently, the complete extir- 
pation was considered impracticable, and even now many 
doubt that it has ever been effected. Allen Burns, Boyer, 
Kicherand and other celebrated anatomists and surgeons, de- 
clared that the safe extirpation of the whole parotid was im- 
possible, but there can be no reasonable ground for rejecting 
the testimony of the distinguished and honorable men who 
claim to have succeeded in the operation. 

The credit of having first demonstrated the practicability 
of this operation by actually performing it, seems to be due 
to Prof. Samuel White, of Hudson, N". Y., who extirpated 
the entire gland for a carcinomatous tumor, in the year 1808. 

Notwithstanding that the patient was examined by expe- 
rienced surgeons, who satisfied themselves of the fact of the 
complete extirpation, the operation was not attempted in Eu- 
rope until 1823. It has since been performed repeatedly on 
both sides of the Atlantic, 

As the result of the testimony now submitted to the pro- 
fession, it is sufficiently determined: 

1st. That the exsection of the parotid, though an exceed- 
ingly difficult, is, in the hands of a good anatomist and 
skilful surgeon, a feasible operation. 

2d. That the carotid artery and its larger branches are 
necessarily implicated in the operation. 

3d. That it is impossible to spare the facial nerve, and 
consequently paralysis is an inevitable result of the ope- 
ration.* 

I think it unnecessary to give any directions, gathered 

* Cooper's Surg. Diet, by Reese. 



338 DISEASES OF THE GLANDS AND GLAND-DUCTS. 

from the experience of the most successful operators, for the 
performance of so very delicate and dangerous an operation as 
the extirpation of the parotid. No sane man will attempt 
it unless perfectly acquainted with the anatomy of the parts, 
and as familiar as reading can make him with the history of 
previous operations. To one thus prepared, there needs but 
the bold heart and expert hand to secure at least the utmost 
likelihood of success which the character of the operation 
will admit. There are no men whose habits of operating 
beget more facility in manipulating, more nice manual dex- 
terity, than dentists, and if they will acquire the necessary 
information, they may become the most expert of operators. 
The example of Dr. S. P. Hullihen, of Wheeling, is worthy 
the imitation of all who would be scientific dental surgeons. 

Salivary Fistula, 
y The duct of the "parotid gland, called the duct of Steno, 
emerges at the upper extremity of the middle third of the 
anterior edge of the gland, and proceeds forward and inward, 
directly under the skin, and on the masseter muscle. It is 
distant from three to five lines from the lower edge of the 
zygoma. It passes on the anterior edge of the masseter 
muscle, penetrates between the fibres of the buccinator 
muscle, and opens in the lateral walls of the cavity of the 
mouth opposite the first posterior molar tooth of the upper 
jaw according to Meckel, the second molar according to 
Harris, and the second and third bicuspis according to 
Cooper — the situation of the opening differing somewhat in 
different subjects. 

This duct being very superficially situated, is exposed to 
injury, and is often wounded by an incautious operator, or 
by a blow. Sometimes, also, the duct may be obstructed by 
the pressure of a tumor or by inflammation. In such cases 
the saliva will accumulate until it makes a passage through 



DISEASES OF THE GLANDS AND GLAND- DUCTS. 339 

the cheek, and continuing to pass through the opening, will 
form a permanent opening, which is called salivary fistula. 

The discharge of the saliva over the cheek is very annoy- 
ing, and the artificial opening is a very serious deformity. 

A variety of methods have been employed to cure salivary 
fistula. Monro inserted a seton from the external fistulous 
opening into the mouth, and kept it there until a new fistula, 
open both on the cheek and in the mouth, had been fully 
formed. He then destroyed the edges of the external open- 
ing with lunar caustic, and caused adhesion between the 
new surfaces produced by the sloughing of the superficial 
eschar. The saliva of course continued to flow through 
the fistulous channel into the mouth. 

Desault also employed a seton, but he introduced it through 
a canula, as follows : Placing two fingers of his left hand 
into the patient's mouth, and placing them between the 
teeth and cheek opposite the fistula, he introduced a smal] 
hydrocele trocar in its canula, through the cheek, just before 
the opening of the posterior part of the duct, and in a 
direction inclined a little forward. An assistant now took 
hold of the canula, while Desault withdrew the perforator 
and passed a line of thread through the tube into the cavity 
of the mouth. The canula was then taken out, and a seton, 
which was then fastened to the end of the thread in the 
mouth, was drawn from within outwards, but not so far as to 
come between the edges of the external opening, where the 
thread alone lodged, and this was fastened with sticking 
plaster to the outside of the cheek. The outer wound was 
dressed with lint and compresses. Desault used to change 
the seton daily, introducing regularly rather a larger one, 
and always taking particular pains not to permit it to pass 
between the edges of the external opening. 

The patient was enjoined to use the jaw as little as possible, 
and for some time confined to liquid food. In about six 



340 DISEASES OF THE GLANDS AND GLAND-DUCTS. 

weeks he omitted the seton, leaving in the thread for a little 
while longer. This being taken away, he completed the 
cure by touching the little aperture remaining, with caustic. 
Beclard succeeded several times, by passing a leaden stilet 
from the inner surface of the cheek into the duct, at the 
point where it was obstructed. He then made a flesh incised 
wound of the external fistulous opening, and closed it with 
the twisted suture. 

Mr. Samuel Cooper prefers the operation of Beclard, when 
possible, as causing a more speedy cure. 






CHAPTEK XIX. 

TUMORS REQUIRING AMPUTATION OF A PART OR THE WHOLE 
OF THE UPPER JAW. 

The superior maxillary bone is frequently the seat of 
tumors, which from their enlargement, interfere with the 
functions of speech, deglutition and respiration, and often 
prove fatal. 

Some of these tumors are of the malignant fungous variety. 
These, commonly, are seated in the antrum. The first indica- 
tion of their presence is an aching of the face, which is 
usually attributed to tooth-ache, but which continues and 
aggravates, notwithstanding all the efforts to alleviate it. 
The jaw rapidly swells, and the nostril of the affected side 
is soon obstructed to respiration, and discharges matter. 
The walls of the antrum are soft, and yield readily to pressure. 
The nostril is filled with a bleeding tumor. The disease 
rapidly progresses — finds its way into the throat, detaches 
and pushes forward the teeth, throws out an enormous fun- 
gus into the mouth or on the cheek, hectic and emaciation 
rapidly reduce the patient, and he soon succumbs to aggrava- 
ted suffering. 

With such a disease as this, we have no means of contend- 
ing. An operation would be worse than useless. Fortu- 
nately, its progress is rapid, and death speedily brings the 
ardently desired relief. 

There is another form of tumor, which commences in the 
periosteum and bone, often from some accident, as a blow or 



342 TUMORS REQUIRING AMPUTATION. 

fall. This tumor is of slow growth, and is solid and resisting. 
It is little sensitive, does not bleed, nor involve surrounding 
tissues except mechanically by its growth. In short, it is a 
tumor of the benign kind, not connected with constitutional 
disease, and it may be removed with entire safety. 

In proceeding to remove a tumor of this kind, involving 
the superior maxillary, the surgeon must have in view, 1st. 
To take away every portion of the disease ; and 2dly. To 
cause as little deformity as possible. The tumor should be 
got out whole ; any incision into it would probably induce 
an embarrassing hemorrhage. 

The operation itself is by no means dangerous, as com- 
pared with other amputations, and it may be performed with- 
out much difficulty, by a dexterous and confident surgeon. 

Mr. Liston's directions for performing the operation are as 
follows : " Having to work among bones, you must use a 
good strong and broad knife — one with which you can make 
free and proper incisions. To uncover a very large tumor, 
you may make one incision from the point of the cheek-bone 
to the corner of the mouth, carrying it outwards also in the 
direction of the zygoma ; another from the angle of the eye 
to the middle of the upper lip. The mark of these incisions 
must always be more or less apparent. But if you have a 
tumor of moderate size to deal with, you should make one 
incision from the angle of the eye, down the side of the nose, 
bring it under the alae, and cut away the alse from the edge 
of the superior maxillary bone ; then you bring the cut down 
well towards the columna nasi, push the knife through the 
lip, and cut right down the median line. A scar from that 
incision will scarcely be perceived if the parts are cleverly 
and carefully put together. 

You make another and much less extensive incision from 
the same point, in the course of the fibres of the orbicularis 



TUMORS REQUIRING AMPUTATION. 343 

palpebrarum, out towards the zygoma, carrying the knife 
under the eye ; you can then turn downwards and outwards 
a large flap, uncover the tumor, and get to the processes of 
the bones. These being divided, the tumor almost tumbles 
out. 

Before commencing your incision, or after you have turned 
the flap back, you may require to take out one tooth, and 
you remove the lateral incisor. You must be provided with 
strong- edged cutting forceps for dividing the bones, and very 
strong scissors for separating longitudinally the palatine 
arch. Before applying them, you cut a notch out of the 
alveolar process of the tooth removed, with the point of the 
cutting forceps. Yery often you are compelled to take away 
the os mala, or perhaps you may saw it through. Supposing, 
that you are going to take away the os mala by the forceps, 
you divide the zygomatic arch and also the junction of this 
bone with the frontal bone, at the transverse facial suture. 
You cut the nasal process of the maxillary bone; then 
putting one blade of the scissors into the nostril, and the 
other into the mouth, cut down, and you have destroyed all 
the attachments of the tumor. You must next carefully 
detach the parts with the orbit, cutting the superior maxil- 
lary nerve far back ; that must not be drawn out from . its 
origin ; then putting your finger on the tumor, you detach 
with your knife any remaining connections, and out tumbles 
the mass. You will be astonished to find how little blood 
follows an operation of this kind; it can be done in a very 
few minutes. There is seldom any necessity for stopping 
the bleeding temporarily by pressure on the carotid ; after 
you have turned the tumor out, perhaps you will not find a 
single vessel to tie, or only one. You take hold of that 
with the fingers, put on a ligature, and then lay the flap 
down. The tumors should come out quite entire, and after 
stopping any vessel that may bleed, you put a dossil of lint 



344 TUMORS REQUIRING AMPUTATION. 

into the cavity, bring over the flap, and put the parts neatly 
together. 

"You introduce some points of interrupted suture under 
the eye and by the side of the nose ; you attach the alae, and 
then put two points of twisted suture into the upper lip. 
In a short time the cavity fills up ; and it is altogether an 
exceedingly satisfactory operation. I have extirpated the 
upper jaw to remove fibrous tumors, nine or ten times, with- 
out the loss of a single patient. It is an operation more 
successful than the amputation of the leg, or, at all events, 
of the thigh, and is attended with as little risk." 

AMPUTATION OF THE LOWER JAW. 

The lower jaw is also sometimes the seat of tumors, which 
may, like those of the upper maxillary, require the use of 
the knife. 

These tumors sometimes consist of a deposit of a glairy 
fluid between the plates of the bone, gradually distending 
it: sometimes they are malignant, at others they consist of 
cartilage and bone. 

Portions of the lower jaw have very frequently been taken 
away, and sometimes with but little difficulty. It occasion- 
ally happens, however, that a very large portion, even the 
whole, requires to be removed. 

In exsecting a portion of the lower jaw, it is very impor- 
tant to avoid unnecessary disfiguration, and our ingenious 
countryman, Dr. Ehea Barton, has made an excellent sug- 
gestion on this point. 

It is to preserve a rim or margin of the bone, so as to pre- 
serve the outline of the face, and afford a base for the inser- 
tion of false gums or teeth. In all cases where the extent 
of the disease will permit, this should be done, as the rim of 
bone thus preserved will be of immense use to the patient. 

The incision through the soft parts should be made beneath 



TUMOKS BEQUIKING AMPUTATION. 345 

the base of the jaw, so as to hide the cicatrix as much as 
possible. 

Prof. Mutter has succeeded in detaching a tumor with a 
portion of the jaw, without any external incision or defor- 
mity whatever. This tumor was seated upon the symphysis 
and two-thirds of the left ramus of the bone. The patient 
being seated, with her head supported by an assistant, the 
tumor was laid bare fn its whole extent, by detaching the 
lip and integuments of the chin and cheek from the adjacent 
bones. No external incision was made, yet Dr. M. had no 
difficulty in turning the soft parts down under the bone, so 
as to leave its base perfectly visible. Next, partly with a 
saw and partly with a strong scalpel, he cut through the 
base of the tumor, leaving a small rim of the bone, composed 
of the rounded portion of the lower jaw. Two perpendicu- 
lar cuts were then made, ( one on each side of the mass,) with 
the cutting forceps — and the tumor, thus loosened, was 
readily removed with a few strokes of the scalpel. As the 
hemorrhage was profuse, the actual cautery and pledgets of 
lint steeped in creosote were applied, and with entire suc- 
cess. The lip was then brought back to its original position, 
and cold water dressing applied to the face. A perfect cure, 
without the slightest, deformity, was accomplished in two 
weeks. 

To our countryman, Dr. Mott, is due the honor of having 
first attempted, and executed successfully, the amputation of 
the lower jaw at the articulation; after him, Mr. Cusack, of 
Dublin, performed it. According to a note by Dr. Eeese, in 
Cooper's Surgical Dictionary, the operation had not been 
performed by any others up to 1842. Mr. List on, in his 
lectures delivered in 1844, speaks rather sneeringly about the 
" fuss" made about extirpating the jaw, and gives the credit 
of the operation to Mr. Cusack, of Dublin. He then proceeds 
to describe it as though it had been an every day operation 
23 



346 TUMOES EEQUIKING AMPUTATION". 

with. him. This conduct of Mr. Liston is remarkable enough, 
but it is more strange that his editor, Prof. Mutter, has not 
corrected the error, and done justice to Dr. Mott. 

The operation is one of the utmost difficulty, and it is use- 
less to give any directions for its performance. None but a 
surgeon of well tried skill would be justifiable in undertaking 
it, and such a one would pay but little attention to directions. 
These of Mr. Liston may be well enough, but we do not know 
that he ever performed the operation on a living body. 

Dr. S. P. Hullihen, a practising surgeon dentist, of Wheel- 
ing, and one of the best surgical operators in this country, 
has performed an operation upon the jaw, which well de- 
serves to be recorded here. As Dr. Harris justly remarks, 
"the ingenuity, skill and boldness displayed in the concep- 
tion and performance of this complicated operation, place Dr. 
Hullihen at once among the ablest surgeons of the day." It 
is the more worthy of notice here, as having been performed 
by a dentist who thus furnishes a model of what we would 
have a dentist to be — not a mere mechanic, employed to re- 
pair the teeth, or, if necessary, extract them — but an accom- 
plished physician and surgeon, who, while devoting his at- 
tention particularly to the teeth, is prepared to undertake 
the treatment of the adjacent parts, however formidable and 
complicated their diseases may be. 

"Miss Mary S , aged 20, daughter of the Hon. William 

S , of Ohio, came to Wheeling, in the spring of 1848, to 

obtain relief from the effects of a very severe burn, which 
she had received fifteen years before. The burn was prin. 
cipally confined to the neck and lower part of the face, and 
its cicatrix produced a deformity of the most dreadful cha- 
racter. Her head was drawn downwards and forwards, the 
chin was confined within an inch of the sternum, the under 
lip was so pulled down that the mucous membrane of the left 



TUMORS REQUIRING AMPUTATION. 347 

side came far below the chin, the under jaw was bowed 
slightly downward; and elongated particularly its upper 
portion, which made it project about one inch and three- 
eighths beyond the upper jaw. In front there was scarcely 
any appearance of either chin or neck. She was unable to 
turn her head to either side, the cheeks and upper lip were 
dragged considerably downward; she could not close her 
eye-lids; she could not close her jaws but for an instant, and 
then only by bowing her head forward. She could not re- 
tain her saliva for a single instant; and, as might be ex- 
pected, her articulation was very indistinct. 

" She had been taken to the city of New York some years 
before, for the purpose of being relieved from this deformity, 
and was placed under the care of two of the most distin- 
guished surgeons in that city, who performed an operation 
by dissecting up the cicatrix on the neck, then raising the 
head and sliding up the cicatrix from its original position, 
leaving a raw surface below to heal up by granulation. I 
need scarcely add that the operation was entirely unsuc- 
cessful. 

"After a careful observation of the case, it became evident 
that such a complicated deformity could be best remedied by 
performing three separate operations: one upon the jaw, 
another upon the neck, and a third upon the under lip. 

"To remove the projection of the under jaw, seemed to re- 
quire the first attention. Unless that could be done the 
other operations, however successful, would add but little, 
if any, to the personal appearance of the patient. This 
lengthening of the jaw had taken place entirely between the 
cuspidatus and first bicuspid tooth of the right side, and be- 
tween the first and second bicuspids of the left. By the 
elongation, the teeth just described were separated on both 
sides about three-fourths of an inch. 



348 TUMOKS REQUIRING AMPUTATION. 

" To saw out the upper edge of these elongated portions 
of the jaw, and then to divide that part of the jaw in front of 
the spaces thus made, by sawing it through in a horizontal 
manner, so as to permit the upper and detached portion to 
be set back in its original position — appeared to be the only 
possible way of remedying the deformity. This plan I there- 
fore adopted, and performed the operation on the 12th day 
of June, in the manner now to be described : 

"The operation was commenced by sawing out, in a Y 
shape, the elongated portions, together with the first bicuspid 
on the left side, each section extending about three-fourths 
of the way through the jaw. I then introduced a bistoury 
at the lower point of the space from which the section was 
removed on the right side, and pushed it through the soft 
parts close to and in front of the jaw, until it came out at the 
lower point of the space on the left side. The bistoury was 
then withdrawn, and a slender saw introduced in the same 
place, and the upper three -fourths of the jaw, containing the 
six front teeth, was sawed off on a horizontal line ending at 
the bottom of the spaces before named, the detached portion 
being still connected, on the outer and inner sides, to the jaw 
below, by the soft parts. 

" After having with the bone nippers removed from the 
detached portion the corners which were created by the hori- 
zontal and perpendicular cuts of the saw, it was set back, so 
that the edges from which the V shaped sections were re- 
moved came together. 

"Thus it will be perceived that this portion of jaw and 
teeth, which before projected and inclined outward, now stood 
back and inclined inward, and in its proper and original 
place. 

"In this position the jaw was secured, by passing ligatures 
around the cuspidati in the detached portion and the now 



DISEASES EEQUIKING AMPUTATION. 349 

adjoining biscnpids in the sound portion, then taking an im- 
pression of the jaw in very soft wax, a cast was procured, and 
a silver plate struck up and fitted over the teeth and gum, in 
such a manner as to maintain the parts in that same relation, 
beyond the possibility of movement. 

" The patient declared that the operation gave her little or 
no pain. There was a little swelling about the chin during 
the first three days after the operation, but not the slightest 
uneasiness. In this way the case progressed ; the gum healed 
in a few days, the jaw united strongly and in the time bones 
usually unite, and the wearing of the plate was discontinued 
within six weeks after the operation was performed. 

"The deformity of the jaw being now removed, the next 
thing to be done was to relieve the confined condition of the 
head, and the distortion of the face and neck resulting there- 
from. This I determined to accomplish, if possible, after the 
manner of Prof. Mutter in similar cases, and I accordingly 
performed the operation on the 31st day of July, assisted by 
Dr. Wissell. 

"I began by dividing the skin immediately in front of the 
neck, about half an inch above the sternum, and then carried 
the incision back about three inches on each side. I then 
commenced a careful division of the strictures which were so 
thickened in front as to extend to the trachea, and on the 
sides as not only to involve the platysma myoides, but a por- 
tion of the sterno-cleido-mastoid muscle also. After dividing 
every thing that interfered with the raising of the head and 
the closing of the mouth, as far as the incision was now made, 
it became evident that to give free motion to the head, the 
incision on the neck must be extended back through the re- 
maining cicatrix, which was at least two inches wide on one 
side, and about an inch and a half on the other. 

"This was accordingly done, the whole presenting a wound 
upwards of nine inches in length and nearly five in width. 



350 DISEASES EEQUIEING AMPUTATION. 

A thin piece of leather was now cut in shape of the wound, 
but somewhat larger, and placing it upon the shoulder and 
arm, immediately over the deltoid muscle, a flap nearly ten 
inches in length and five in breadth, having an attachment 
or neck two inches wide, was marked out, and then dissected 
up as thick as the parts below would permit. This flap was 
now brought around and secured in the wound on the neck 
by the twisted suture, the sutures being placed about an 
inch and a half apart. Between each of these sutures, one, 
two, and sometimes three small stitches were inserted, de- 
pending entirely upon the number necessary to bring the 
edges neatly together. These stitches were of fine thread, 
had a very superficial hold, produced little or no irritation, 
and served to keep the parts in better apposition than any 
other means I could have devised. The wound of the shoul- 
der was next drawn together about one half of its entire 
extent ; the remainder was covered with lint. One long nar- 
row strip of adhesive plaster applied round the neck to sup- 
port the flap, and over this a cravat tied in the usual way, 
constituted all the dressing deemed advisable at this time. 

" The patient bore this tedious and very painful operation 
with great fortitude, and uttered scarcely a murmur. She was 
somewhat exhausted, but not from the loss of blood. There 
was no vessel divided of sufficient importance to require a 
ligature. 

"Aug. 1. During the fore part of last night the patient 
was somewhat distressed, was very unmanageable, would talk 
incessantty, and occasionally sat up in bed. An anodyne 
was administered at 12 o'clock, after which she rested much 
better and slept some. Complains of sickness of the sto- 
mach this morning ; has vomited three or four times ; flap 
very pale; pulse rather weak. Directed to refrain from all 
kinds of drinks. 

" 2d. Complains only of pain in the shoulder ; was much dis- 



DISEASES BEQUIKING- AMPUTATION. 351 

tressed the latter part of last night, on account of a retention 
of nrine. The catheter was employed, and about three pints 
of urine drawn off, after which she rested well. Pulse some- 
what excited; flap better color. 

"3d. The patient rested well last night; the use of the ca- 
theter still necessary. All efforts to keep the patient from 
talking and moving unavailing ; color of the flap rather pale 
save at the extreme point and about two inches along the 
lower edge, which is assuming rather a dark blue color. 
Pulse about the same as yesterday ; removed a pin from near 
the point of the flap, and enveloped the neck in cotton bat- 
ting. Patient complains of hunger ; chicken broth ordered. 

* 4th. Patient rested well ; the use of the catheter yet neces- 
sary; complains of slight headache; the color of the flap 
nearly natural, and even the point is assuming a healthy hue, 
and appears to be uniting; pulse almost natural. 

"5th. Urinates without difficulty; bowels moved by injec- 
tions ; patient entirely free from pain ; pulse natural. 

u 6th. Dressing removed ; the flap is uniting by the first in- 
tention along both sides, throughout its entire extent; the 
greater part of the pins and stitches removed. 

u 7th. The remainder of the pins and stitches removed ; pa- 
tient perfectly comfortable and cheerful. 

" 10th. Sat up all day by the window. 

"16th. Walked out to take an airing. 

"During the whole progress of the cure, there was not the 
slightest swelling or undue inflammation in the flap or about 
the neck. The patient was slightly hysterical for the first 
few days, but never complained of any thing but pain in the 
shoulder, a slight headache of a few hours' duration, and the 
uneasiness occasioned by the retention of urine. The wound 
on the shoulder granulated rapidly and skinned over in 
about six weeks after the operation. It was curious to ob- 
serve that upon touching the flap after it had healed in the 



352 DISEASES REQUIRING AMPUTATION. 

neck, the patient would always refer the sensation to the 
shoulder or arm from which the flap was taken. 

"The confinement of the head, and the distortion of 'the 
face occasioned by the strictures being now removed, the 
next step was to relieve, as far as possible, the very great de- 
formity of the under lip.' 

"The under lip, from being dragged down and greatly 
stretched by the former projection of the under jaw, was ren- 
dered greatly too large, so that it pouted out an inch or more 
further than the upper lip. This, together with a turning out 
of mucous membrane on the left side, which extended 
nearly down to the lower edge of the chin, making the lip too 
short on that side, was the nature of the deformity yet to be 
relieved. 

" To remove this unseemly appearance of the lip the in- 
verted portion was cut out in a V shape, extending down 
to the flap in the neck, and sufficiently large to reduce the 
lip to its proper size. The edges were then brought to. 
gether, and secured after the manner of a single hare-lip. 
The wound healed in the most beautiful manner, and the ap- 
pearance of the lip was greatly improved ; but there yet re- 
mained a deep depression or notch in the edge, sufficiently 
large to keep exposed the tops of two or three teeth, besides 
preventing the coming together of the lips on that side. 

"I now determined to raise, if possible, this depressed por- 
tion of the lip, and for this purpose I passed a bistoury 
through the lip, about two lines from the free edge, first on 
one side of the depression, and then on the other, and then 
carried the incisions downward to meet at a point on the 
lower edge of the chin. 

"The depressed portion of lip now lying between the two 
incisions was next dissected loose from the jaw, and then 
raised to a level with the remainder of the lip, and there re- 



TUMORS REQUIRING AMPUTATION". 353 

tained by pins, after the manner of dressing a double hare- 
lip, the line of union forming a letter V. 

"This operation was as successful as the others, and the 
original deformity being now removed, the young lady, 
though still bearing evidences of the burn, has the free use 
of her head, eye-lids, jaws and lips, and may mingle in socie- 
ty without particular note or remark," 



CHAPTEK XX. 

DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

The cavity which, bears these names is liable to be the 
seat of a variety of diseases. For the most part these are 
simple, and not at all malignant in their character ; occasion- 
ally, however, tumors and ulcers of a carcinomatous kind fix 
their seat in this secluded cavity, where their presence is un- 
observed until their local devastations or constitutional im- 
pressions have reached a most serious extent. 

The danger of diseases of the antrum, however, cannot be 
estimated entirely by their specific character. The rela- 
tive situation of the cavity gives greater importance to its 
diseases than essentially belongs to them. Many a benign 
tumor, originating here, has proved fatal by mere growth 
and bulk ; the danger having been masked by the concealed 
position and the little sensibility of the parts, until interfe- 
rence was useless. 

Nothing can be more important, therefore, than early at- 
tention to any of the commonly obscure symptoms which in- 
timate the presence of the diseased action of any kind in this 
pathologically important sinus. The dentist commonly has 
the first opportunity to observe these signs and detect their 
cause, and he should always be ready to perceive and inter- 
pret them. 

The lining membrane of the antrum is liable to be affected 
by all the diseases common to the mucous tissues. It may 
be congested, inflamed and ulcerated; it may undergo alter- 



DISEASES OF THE ANTKUM OR MAXILLARY SINUS. 355 

ations affecting its secretions, it may be the seat of various 
tumors, or may be involved in such morbid formations com- 
mencing in the bony structures or the thin fibrous tissue 
which attaches it to the bones. 

In treating further of diseases of this cavity, I will ask 
the attention of the reader to, 1st. Dropsy or retention of mu- 
cus; 2d. Inflammation of the lining membrane; 3d. Sup- 
puration ; 4th. Caries, necrosis and other morbid conditions 
of the bony walls ; 5th. Polypi and other tumors ; 6th. The 
presence of insects in the cavity. 

Dropsy, or Retention of Mucus. 

The term dropsy is entirely misapplied to this affection, 
and should be discarded. The disease has no similarity to 
dropsical swellings : those are occasioned by effusion of wa- 
ter, while the affection we are considering is a distention of 
the antral cavity by retained mucus. 

If from any cause the antral openings become closed, the 
secretion of the lining membrane, no longer finding exit by 
evaporation, must accumulate in the cavity of the sinus. 
Being retained, it will necessarily degenerate; being degene- 
rated, it will irritate the membrane, and the membrane being 
irritated, will pour out more than its usual quantity of secre- 
tion. The quantity accumulated will at length completely 
fill the cavity, and when once the sinus is completely filled, 
every additional drop of fluid thrown into it will cause the 
whole mass to act with great power upon the walls which 
confine it. However thick the walls, and however strongly 
knit together, they cannot withstand the hydraulic pressure 
continually augmenting within them. They are gradually 
forced outwards, and a rounded solid tumor gives external 
evidence of the outward pressure of the contained fluid. 

Until the pressure becomes sufficient to distend the bones, 



356 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

the patient does not complain of pain ; but as the walls of the 
cavity gradually yield and press upon the soft parts, pain is 
felt, which becomes more and more severe as the tumor in- 
creases. The integuments covering the distended antrum 
become swollen and red. A smooth hard tumor presents it- 
self either in the roof of the mouth, or under the orbit, or 
under the cheek, and unless the contained fluid be speedily 
evacuated, the contents of the antrum will force their way 
through the bones. 

As the distention of the walls of the sinus indicates no- 
thing more than the fact of its being filled with some distend- 
ing body, it may often be difficult at first to decide whether 
the contents be mucus or some kind of solid growth. So long 
as the tumor presents a tolerably uniform hard surface, there 
can be no certainty of the nature of the distending cause ; 
but the uniformity of the tumor, the sense of weight, the 
slight discomfort or pain attending it, and, finally, the dis- 
covery of fluctuation will determine the diagnosis. 

The indication, of course, is to make an artificial opening 
and permit the escape of the contained matter, and then to 
make such applications to the lining membrane of the an- 
trum, as will restore the natural secretion of the part. 

There is no difficulty in making the required opening. 
The antrum is accessible at many points, and might be per- 
forated almost anywhere without danger. Yet it is a very 
important thing to choose that point where the wall is 
thinnest, and where the perforation may be made with least 
pain and least injury to the parts, and which affords the 
most facility for the escape of the matter, during such length 
of time as an artificial opening may be necessary. 

Jourdain, a French surgeon, who wrote very ably upon 
diseases of the sinus, recommended to the Academy of Sur- 
gery in Paris, that a sound should be passed into the antrum, 
through the natural opening. He represented that the ope- 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 357 

ration was feasible, and being so, was, for many reasons, pre- 
ferable to any other. Upon experiment, however, this mode 
of procedure has been found very difficult of execution in all 
cases, and altogether impossible in many, and it is no longer 
attempted. 

The fangs of the molar teeth sometimes penetrate the ca- 
vity of the antrum, and generally their extremities are sepa- 
rated from it by a very thin bony partition. The cavity of 
the antrum is depressed posteriorly, and the position of the 
molar teeth represents the most depending part of it. It is, 
therefore, most advisable to make the opening through the 
alveolus of one of these teeth. Should one have been previ- 
ously extracted, we should make the opening through its va- 
cant alveolus ; should all these teeth be yet in the jaw, one 
must be extracted, and of course, we should sacrifice a ca- 
rious, in preference to a sound tooth. Should all be sound, 
it would be best to extract the second molar. Sometimes it 
will be necessary to extract two teeth, in order to obtain suf- 
ficient room for such an opening as will be desirable. 

Sometimes the extraction of the tooth will be followed at 
once by the discharge of the fluid ; an opening having been 
made into the antrum by tearing away the fang. More ge- 
nerally, however, it will be necessary to puncture the floor of 
the cavity. 

The instrument preferred by Dr. C. A. Harris, for whose 
opinion, in such matters, I have great respect, is a straight 
trocar. The point of this instrument having been passed 
into the alveolus, should be pressed against the bottom, in a 
direction towards the centre of the antrum. The inter- 
vening plate of bone, may then be easily pierced by a few ro- 
tary movements of the trocar. Care must be taken so to 
moderate- the pressure applied, that the instrument may not, 
upon the giving way of the floor, be suddenly pushed across 
the cavity and made to wound the opposite surface. 



358 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

Upon the removal of the instrument, a gush of fluid will 
follow. Should the opening not be sufficiently large to per- 
mit of the free passage of the thick matter which may be 
contained in the cavity, it will be easy to enlarge it. 

Some surgeons advise that a bougie should be kept in the 
opening, others prefer a canula of lead or silver. Eichter ob- 
serves, that if a canula be left in, it should be carefully 
stopped, lest particles of food and drink should find their 
way into the cavity. Deschamps and Harris advise that the 
canula be secured to the adjacent teeth, and left in the open- 
ing. If a bougie be used, it should be removed two or three 
times a day, in order to permit the matter to escape. 

If fistulas have previously been formed, they will gene- 
rally close after the dependent opening has been made. 
Should they not heal readily, their closure may be facilitated 
by touching their callous edges with nitrate of silver* 

Having removed the mechanical evil, by evacuating the 
accumulated fluids, we must accomplish a cure by such con- 
stitutional treatment as the case may require, and by suita- 
ble local applications to the lining membrane of the antrum. 

At first, warm water may be injected, in order thoroughly 
to cleanse the surface of the membrane, and subsequently we 
may throw in astringent or mildly stimulating applications, 
such as port wine and water, solutions of sul. zinc, sul. cupri, 
or even of nit. argenti. As the secretions are fetid, a weak 
solution of chloride of lime, or chloride of soda, may be in- 
jected two or three times a day. Should the gums be in- 
flamed, leeches must be applied from time to time, until the 
inflammation be subdued. 

As the morbid condition of the mucous lining of the ca- 
vity may result from the irritation of diseased teeth or fangs, 
all suspected irritants of this kind must be removed. 

In Mott's edition of Yelpeau, I find the following remark : 
"If, as happens frequently, the sinus is distended by any 



DISEASES OF THE ANTRUM OE MAXILLARY SINUS. 359 

liquid, its anterior wall swollen out in the form of a border 
under the cheek is, in general, so soft that a bistoury or scal- 
pel penetrates it without any difficulty. The operation is then 
extremely simple. Having freely incised the superior part of 
this border transversely between the cheek and malar bone, I 
excise its inferior portion with a second cut of the bistoury. 
The loss of substance thus made, remains fistulous, and pre- 
vents the sinus from filling up a second time. The three pa- 
tients which I treated in this way were promptly cured." 

Should the teeth have been long previously lost, and the 
alveolus obliterated, the operator must choose between dis- 
secting off the gum and boring his way into the antrum at 
the point already indicated, or performing some one of the 
several other modes of operation which have been preferred. 
Lamorier ■ directs, in such cases, that we should penetrate 
into the maxillary sinus immediately below the zygomatic 
process, between the cheek bone and third molar tooth. 
This is the point which corresponds to the summit of the ca- 
vity, where the walls are thinnest. An assistant, provided 
with a blunt hook, draws the labial angle outwards and up- 
wards. The operator incises the fibro-mucous membrane, 
which covers the bone at the point designated, by means of 
a scalpel or good bistoury ; then perforates the osseous wall 
with a solid pointed instrument, enlarges the opening as much 
as he judges necessary, and finishes by introducing into it a 
tent of lint. 

Other surgeons prefer the method originally suggested by 
Molinetti, first to divide the cheek between the projection of 
the malar bone and the suborbital foramen, then to penetrate 
through this wound into the interior of the sinus. 

In a patient who had no longer any molar teeth, the idea 
occurred to (xooch of perforating the antrum highmorianum 
on its nasal wall, and of inserting therein a leaden canula. 

A buccal fistula of the maxillary sinus suggested to KufTel 



360 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

to penetrate that cavity with a trocar, and to compel it to 
come out above the gum, in order thereby to establish a coun- 
ter opening. A seton was then introduced and kept in this 
passage during the space of six weeks, with such benefit that 
success crowned the enterprise of the surgeon. 

Cullison recommended that if the fluctuation should be- 
come perceptible at the vault of the palate, the artificial open- 
ing should be established there. Basch and Henkel have 
succeeded by means of a meche introduced through a fistula 
in the floor of the orbit, and brought into the mouth through 
an opening in the alveoli. Bertrandi proceeded in the same 
manner, with the exception of not using the seton, in a pa- 
tient who could not open his mouth, and who also had a fis- 
tula in the orbitar wall of the sinus. 

In the process of Weinhold, the surgeon first directs his 
instrument to the upper and outer part of the canine fossa, 
directs it obliquely downwards and outwards, carefully avoids 
the branches of the suborbitar nerve, perforates the sinus and 
then leaves a roll of lint in the wound. If the sinus has no 
other issue, "Weinhold recommends that we should perforate 
it through and through, either by pushing the first instru- 
ment through the palatine vault into the mouth, or by means 
of a curved needle above the alveoli, when we wish to place 
the counter opening external to the gum. An eye which 
both instruments here enables us at the same time to pass 
through the sinus the conducting thread of a meche of lint 
destined to perform the duty of a seton, and which may be 
smeared with any proper ointment* 

The disease we are considering is not by any means serious, 
as it depends upon slight and generally temporary alterations 
in the antral membrane. Kecovery, however, is slow, and 
we must not expect to accomplish a cure under a period of 
several weeks. 

* Mott's Velpeau's Surgery, vol. iii. 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 361 

Inflammation. 

The lining membrane of the antrum may be inflamed from 
a variety of causes. Severe blows upon the face, injuring, 
perhaps breaking, the external walls of the cavity ; cold act- 
ing for a long time upon the face ; the accumulation of mu- 
cus within the cavity, undergoing degeneration, and be- 
coming irritating to the surface upon which it rests — all 
these may, occasionally, induce inflammation of the sinus. 
But, undoubtedly, the most common cause is found in the 
diseases of the teeth, gums and dental periostea, which are 
communicated to the lining of the antrum. 

The chief symptom of inflammation of the sinus, is a dull, 
continuous pain in the upper jaw, gradually becoming more 
severe, spreading to the border of the alveolus, and seeming 
to fix itself in the roots of the molar and canine teeth. It 
sometimes occupies the whole side of the face, extending to 
the orbit and frontal sinus. The inflammation may begin 
in the teeth, and gradually extend to the antrum, in which 
case the severer and more paroxysmal pain of tooth-ache 
will accompany the duller, deeper, more continuous ache of 
the antrum. As the pain increases, fever is developed, 
which will be more or less considerable, according to the 
degree of the inflammation and the sensibility of the patient. 

Inflammation of the sinus can hardly be confounded with 
engorgement. In the latter case there is swelling of. the 
bones, and in the former there is pain from the commence- 
ment of the attack. In fact, it cannot be mistaken except 
for inflammatory odontalgia, affecting the roots of the molar 
teeth ; and from this, if these teeth be decayed, it cannot al- 
ways be distinguished. 

In inflammation of the antrum, we must use leeches to 
the gums, and, unless there be some good reason for omitting 
it, general bleeding from the arm, saline cathartics, and, in 
24 



362 DISEASES OF- THE ANTRUM OR MAXILLARY SINUS. 

short, the whole antiphlogistic means. Opium may be used 
freely to lull the pain, and warm applications, by vapor or 
poultices, may also be tried. 

If, however, there be pain which seems to be similar to 
toothache, and if some of the teeth, especially the molars, be 
diseased, and especially if one or more of them have been 
in the habit of aching, no permanent cure can be expected 
without removing them. 

For the most part, however, we ought not to attempt this 
operation while the inflammation is unsubdued, as the in- 
jury inflicted by the violence of extraction must increase 
the vascular excitement of the part, and aggravate the dis- 
tress of the patient. When the inflammation has been sub- 
dued, and the morbid irritability of the parts has subsided, 
the mouth should be carefully examined, and all diseased 
teeth removed. 

Suppuration. 

The inflammation of the mucous membrane of the antrum 
generally terminates in resolution; sometimes, however, it 
ends in the formation of pus, or suppuration. 

When such is unfortunately the case, the pain gradually 
becomes less intolerable, and finally ceases in a great de- 
gree. The fever subsides, the patient may feel some rigors, 
and instead of acute pain there is felt a throbbing sensation 
in the parte If the outlet of the sinus be open, pus will 
escape into the nostril, and unless it finds a free vent, some 
pointing will, after awhile, be perceived in the alveolar bor- 
der, or a bony protrusion will be noticed upon the cheek. 

Suppuration of the antrum may occur without preceding 
active inflammation. Some cachectic habits are exceedingly 
prone to a slow, feeble inflammation, which is not attended 
by acute symptoms, and is apt to end in the formation of 
ill-conditioned pus, and frequently in ulceration of mucous 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 363 

membranes. This kind of suppuration is not uncommon in 
the antrum, and the inflammation preceding it is not unfre- 
quently unperceived until the greater mischief of suppura- 
tion or ulceration has been accomplished. Even after sup- 
puration, the true nature of the evil may be unsuspected ; 
the more so, that the preceding inflammation has been un- 
perceived. 

When there is dull, continuous pain along the border of 
the sinus, apparently not depending upon caries of the teeth, 
if there be swelling of the sinus, especially if the patient be 
of a strumous habit of body, we may suspect suppuration of 
the sinus. Should pus escape into the nostril, of course the 
diagnosis will be complete. 

If there are any carious teeth, they should be removed. 
They may be the cause of the pain ; they may even be the 
cause of the suppuration. In any case, their presence is mis- 
chievous, and, moreover, we must have access to the cavi- 
ty through the alveoli. 

The. treatment must be similar to that recommended for 
mucous accumulation. Should the disease be the conse- 
quence of general ill health or depraved constitution, the 
proper constitutional means must be employed. The mouth 
must be cleared of decaying teeth, and the patient must avoid 
exposure to cold. 

Caries, Necrosis, and other Morbid Conditions of the Bony Walls. 

Caries is an affection of the bone, somewhat analogous to 
ulceration of the soft parts. In this disease there is loss of 
substance, causing, for the most part, irregular perforations 
of the osseous structure, giving, in many instances, a honey- 
combed or worm-eaten appearance ; at other times the de- 
struction may appear in a continuous superficial excavation. 
There is a discharge of a dark, fetid, sanious pus, and fre- 



364 DISEASES OF THE ANTKUM OR MAXILLARY SINUS. 

quently a growth of fungous granulations snooting up from 
the excavations. 

The bones, though hard and dense, are vital structures. 
They are supplied with blood-vessels and nerves, and cellu- 
lar tissue. They are capable of growth and reproduction, of 
absorption, and separation of dead from the living parts, by 
a vital process. Of course they are subject to disease — and 
to diseases only differing in appearance from those affecting 
softer structures, by the necessary modifications resulting 
from the peculiar density of the osseous structures. 

Caries may occur in bones from the same causes which in- 
duce ulceration in the soft parts. Any thing which lessens 
the vitality of the parts, diminishes its nutrition, or causes 
excessive interstitial absorption, may cause caries. 

External injuries may be the exciting cause, though far 
more commonly productive of necrosis. Long- continued in- 
flammation or irritation of neighboring parts ; inflammation 
of the periosteum, and, above all, certain constitutional vitia- 
tions, are causes of caries. » 

Scrofulous persons, and those whose fluids are tainted 
with the syphilitic poison, are most apt to engender this and 
other diseases of the bones. 

Generally, a fistulous ulcer, somewhere in the vicinity of 
the carious bone, will discharge the dark- colored, fetid and 
often bloody pus which I have mentioned, and this will ge- 
nerally be a sufficient evidence that caries lies beneath. M. 
Strack, however, is quoted by Jourdain, as having met with 
an ulcer in every way similar to those usually marking 
caries, which was, in reality, unconnected with any disease 
of the bone. 

When the finger can be brought in contact with the bone, 
which, however, can rarely be the case, the roughened feel- 
ing of the surface will at once determine the diagnosis. 
When this kind of examination cannot be made, a silver 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 365 

probe may often be passed to the bottom of the fistula, and 
the rough, grated surface of the bone perceived. Very often, 
however, the canal through which the pus escapes is too tor- 
tuous to permit of satisfactory exploration. 

If caries be not checked, it will end in necrosis, or complete 
death of the diseased bone; caries, however, is not necessary 
to necrosis, for the latter may occur without being preceded 
by the former. 

Necrosis may be caused by any means which destroys the 
nutrition of the bone or any part of it. These causes are 
sometimes external; more commonly, perhaps, they depend, 
at least for their predisposing cause, upon constitutional vi- 
tiations, or defects of nutrition consequent upon general 
pravity. 

When the walls of the antrum or alveoli are carious or 
necrosed, the soft parts adjacent inflame, ulcerate, and dis- 
charge a fetid, sanious or ichorous pus. Sometimes the gums 
lose their vitality, become gangrenous, and are slowly sepa- 
rated by sphacelation. 

Dr. Harris observes, that it frequently happens, that while 
caries is preying upon the antrum, its walls become softened 
to such an extent that they may be bent. This alteration 
of the bone, as well as the caries and necrosis, are, he says, 
in almost every instance, preceded by some other affection 
of the antrum. 

Caries and gangrene of the antrum are very distressing 
affections, as, even when there is vitality enough in the bone 
to check the caries or throw off the sequestrum, the process 
is very slow ; the fetid discharge of pus and the extreme sen- 
sitiveness of the inflamed and fungous soft parts, produce 
great misery to the sufferer, and excite the lively sympathy 
of all who witness his distress. The severest operation, which 
promises relief, will commonly be endured with patience by 
the unhappy victim of so protracted and intolerable a disorder. 



366 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. • 

It is not always easy to detect the existence of caries in 
the antrum, as the symptoms manifested by the surrounding 
parts, or detected through them, are similar in different af- 
fections. Should sanious pus make its appearance, we may 
generally infer the existence of caries ; but in a few instances 
the pus has been of a normal character and appearance, and 
though the presence of the pus, in appearance such as com- 
monly attends caries, may satisfy us that such a state of the 
bone exists, the absence of such pus is not equally satisfactory 
evidence that the bone is entire. The exfoliation of pieces 
of bone would of course dispel all doubts as to the nature of 
the disease. 

By probing where there is an ulcer, or by making an ar- 
tificial opening where none exists, we can gently introduce 
a blunt probe and explore the suspected bone. 

When the alveolar border or floor of the antrum is the 
seat of the caries or necrosis, there is little difficulty in ascer- 
taining the seat and nature of the disease. 

The swollen and purplish appearance of the gums will at- 
tract attention to the alveolar border; and soon separating 
from the sockets, ulcerating and sloughing, they will lay 
bare the diseased bone, and expose the true character of the 
disease. 

" When situated in the floor of the antrum, the rough de- 
nuded bone may be easily felt with a probe or stilet, intro- 
duced through the fistula in the gums or alveolus of a tooth 
from which the matter is discharged." — (Harris.) 

Whatever may be the remote causes of caries and necrosis 
of the antral bones, the immediate cause is defective nutrition, 
resulting from disease or destruction of the periosteum ; and, 
among the most common causes of periosteal disease, are the 
irritation produced by diseased teeth, and that caused by the 
action of fluid detained in the cavity. 

The first step towards cure must be to evacuate any mucus 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 367 

which may be distending the antral chamber, and to remove 
any diseased teeth which may be suspected of causing irrita- 
tion. 

The following case reported by Deschamps* will serve to 
show that I have not laid unnecessary stress upon the agency 
of diseased teeth, in the production of caries of the maxillary 
bones. 

Mr. Martin the elder, who enjoyed at Lyons, a well merited 
reputation, communicated to me the following case: 

M. D. had a carious tooth in the upper jaw of the left side. 
A dentist having refused to extract it, a violent inflammation 
occurred in the alveolus, and subsequently was communi- 
cated to the maxillary sinus. The result was a deposit of 
matter in the cavity of the antrum, and consequently a ne- 
crosis of the greater part of its anterior and inferior walls. 

When the patient called upon M. Martin, he was passing 
a bloody and very fetid matter through his left nostril. The 
posterior part of the alveolar border felt denuded, and was 
covered with fetid mucus. Externally a considerable tumor 
occupied all the left side of the face, from the orbit to the bor- 
der of the lower jaw. The appearances fully satisfying Mr. 
Martin as to the nature of the affection, he decided to attempt 
the extraction of the pieces of necrosed bone, in order to 
open a way into the interior of the sinus, and explore the 
state of the lining membrane. 

By the aid of the elevator, he detached a fragment about 
ten lines in length, which appeared to belong partly to the 
alveolar border, partly to the palatine and partly to the ma- 
lar apophysis. 

In the meantime, carrying his finger into the opening he 
had made, he perceived yet two or three rough points, which 
led him to believe that he had not yet got away all the frag- 

* Traits des Maladies des fosses Nazales et de leurs sinus. 



368 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

ments. He postponed farther efforts to the next day. Then 
he took away another fragment which appeared to belong to 
the anterior wall of the sinus, and which was larger than 
the piece previously removed. After this he could find no 
more asperities, and he assured the patient that the opera- 
tion, so far as the extraction of bone was concerned, was com- 
pleted. No fungus could be perceived, and after the first 
day, the discharge of pus through the nostrils and mouth had 
nearly ceased. 

In less than five days, the tumor of the cheek had subsided ; 
the patient suffered no pain, and his breath ceased to be fetid. 
The only remaining inconvenience was an imperfection of 
speech, which resulted from the communication between the 
sinus and the mouth, and which would be remedied when 
the opening of the alveolus should be closed either by the 
junction of the gums or reproduction of osseous matter. 

Dr. Francis, of New York, describes a form of this disease 
which occurs in infants in hospitals, and under circumstances 
when the nutrition is impeded, as by scrofula, unwholesome 
air, insufficient aliment, &c. The disease frequently begins 
at the edge of the gums in contact with the incisor teeth. 
The soft parts become tumid with hardness and pain. Some- 
times the greater part of the side of the face assumes an ery- 
thematous aspect without any premonitory signs ; and this is 
subsequently marked by spots of a dark purple or brown 
color. Sometimes the part becomes speedily sphacelated, 
sloughing commences and emits fetid exhalations. The 
tongue is loaded with a foul sordes, and the breath becomes 
exceedingly offensive, when coma will supervene and death 
suddenly ensue. In other instances the teeth will become 
loose in the commencement of the disease, and not unfre- 
quently drop out on the slightest exertion or motion of the 
jaw. The necrosis, in some cases, will involve full one side 
of the jaw, and the ulceration extend equally over the soft 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 369 

parts and affect the alae nasi, the nose itself and the cheek 
nearly to the orbit of the eye. Yery soon the sphacelated 
flesh falls in, and the internal structure of the mouth will be 
exposed, while the lips will become tumid, painful and dis- 
colored. These morbid changes, to a greater or less extent, 
are found to involve, very speedily, the teeth, alveoli, mu- 
cous surfaces and cheeks. The disease is very dangerous, 
and often rapidly fatal. 

In these cases, the disease is evidently the effect of consti- 
tutional causes, and no local treatment can arrest the devas- 
tation. It was once fashionable for surgeons to make use of 
the most violent means for the cure of caries. The diseased 
bone was cut or burnt away, and the subjacent part carefully 
cauterized with a red hot iron, in order to prevent the spread 
of the disorder. Such terrible means were rarely justifiable. 
When the disease is entirely local, and the constitution 
sound, all that the surgeon can do is to remove the cause of 
the caries, if yet existing — to lay bare the diseased part in 
order to give egress to the fluids, and admit the atmospheric 
air, which is a stimulant to the parts — or any other moderate 
stimulant which may seem likely to hurry the process by 
which the great surgeon, nature, is limiting and repairing the 
injury. The diseased parts should be cleansed with astrin- 
gent and detergent washes ; loose pieces of bone should be 
removed, and the patient rendered as comfortable as possible, 
and properly sustained by such nutriment as may be best 
adapted to his state of strength. Meddlesome surgery is 
bad. 

When there is constitutional disorder, causing caries, or 
preventing the curative process, there will be no prospect of 
relief, unless the constitutional disease be removed. If the 
venereal poison has tainted the system, it must be counter- 
acted by the specific means which so generally neutralize it. 
Should scrofula be the form of constitutional pravity, we 



370 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

must use, with far less hope, those general measures of regi- 
men, diet and medication, which promise most in such cases. 

When necrosis has taken place, the bone must be removed. 
By doing this, we do not interfere with, but assist nature, ac- 
complishing at once, by mechanical means, what by the na- 
tural effort might not have been effected during weeks or 
months. 

Should a very large opening be made in the floor of the 
antrum, it may not be closed by the unaided efforts of na- 
ture. In such case, it has been recommended to cauterize 
the interior circumference of the opening, in order to remove 
the edges, and induce greater activity in the parts. If the 
opening has been too great to permit of closure by the pro- 
cess of reproduction, we must make the best substitute we 
can for the lost parts, as it is imperatively necessary to close 
the cavity. "An obturator of gold should be accurately fitted 
to the parts, and secured by means of a broad clasp to a mo- 
lar or bicuspid tooth ; and if there be none suitable on the 
side of the mouth to which it is to be applied, the gold should 
be extended to one on the opposite side. If it be necessary 
to replace the teeth lost with artificial ones, these may be so 
mounted that the plate upon which they are set shall cover 
the opening into the maxillary sinus, and thus obviate the 
necessity of any other obturator." — Harris. 

Softening of the Bony Walls. 
Mollities ossium, or softening and increased flexibility of 
the bones, is due to a diminution of the normal quantity of 
the phosphate of lime, to which earthy ingredient the hard- 
ness of the bones is due. This may occur either from ab- 
sorption of the earthy matter, or failure of the arteries to 
deposit it in sufficient quantity. It is a rare disease, but it 
sometimes occurs in the antrum. Unless accompanied by a 
similar condition in other osseous structures, it may be re- 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 371 

garded as the consequence of some pressure from within the 
cavity, either by a tumor or contained fluid. So far as the 
softening itself is concerned, it cannot be considered a subject 
for medical or surgical treatment. 

Exostosis. 

This affection is a hypertrophy or morbid growth of the 
bone, in which the phosphate of lime is deposited in unusual 
quantity, and a hard tumor occasioned. It is not painful of 
itself, but by distention of the periosteum and superincum- 
bent soft parts, it may gradually become a source of great 
distress. Generally, however, as the tumor augments slow- 
ly, the soft parts adjust themselves to the increased bulk of 
the bone, and the patient escapes serious suffering. Much, 
however, will depend upon the magnitude and position of 
the swelling, and upon the attendant condition of the peri- 
osteum. Should this be inflamed and sensitive, it may oc- 
casion acute pain. 

I have already described this kind of morbid growth, in 
treating of tumors. 

The bones of the face have very often been the seat of 
exostosis, and many formidable operations have been per- 
formed for the removal of such tumors. A number of such 
cases and operations have been described, both by the older 
and modern surgeons. * 

These tumors sometimes attain to great size. M. Beau- 
preau presented to the French Academy, in the year 1767, an 
anatomical preparation, consisting of a tumor which occu- 
pied the whole right maxillary sinus, and several of the 
neighboring bones. Its largest circumference is about twelve 
inches. The upper part of the maxillary bone projects on 
the side of the orbit, and straightens the cavity ; the os un- 
guis is included in the mass of the tumor, and is nearly ef- 

* See Mott's Velpeau, vol. iii. p. 134. 



372 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

faced. The nasal bones of the left side are displaced, and 
the right nostril entirely closed up ; and the exostosis pro- 
jects so much on the left side as to be nearly under the ma- 
lar bone. "Exteriorly," says Bordenave, "the tumor had a 
smooth and polished appearance, and its upper part was 
very hard. Interiorly, the substance of the bone was spongy, 
and not unlike pumice-stone. 

Sir Astley Cooper describes a case of exostosis of each an- 
trum, which pushed out both eyes, and eventually destroyed 
the patient by pressure upon the brain. 

Jourdain notices an interesting case of this kind, reported 
by M. David, chief surgeon of the Hotel-Dieu of Eouen, and 
adds the following, which came under his own observation : 

Joseph Forgade, surgeon, had a son who in early life gave 
promise of great vigor of mind and body. "When six years 
old, he had the small-pox, which ran a most favorable course. 
When twelve years old, his father lanced a tumor at the 
inner can thus of the right eye, which suppurated for a long 
time after. Immediately after this, a prominence appeared 
about the middle of the nasal process of the right superior 
maxilla ; and in spite of every application, steadily increased 
until it had attained considerable size. When the boy was 
fifteen, both maxillas were equally enlarged ; the bones of the 
nose seemed buried between the tumors, and its cartilages 
were so compressed as to impede breathing. The defor- 
mity was great, and at the age of twenty became, by the 
growth of the tumors, monstrous. The lower jaw became also 
exostosed, and acquired a very great size. 

Though the deformity was shocking, it did not prevent 
the lad from travelling about and gratifying his naturally cu- 
rious disposition. He was clever, lively, fond of good living, 
and particularly of stimulating drinks. At the age of forty- 
four he was seized with a malignant fever, — his first sickness 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. S73 

since infancy, — from which he was slowly recovering, when 
he was seized with pneumonia, of which he died. 

Upon post-mortem examination, says Jourdain, I could 
find on the face no trace of any muscles except those of mas- 
tication ; but the skin seemed tightly drawn over the perios- 
teum covering the numerous tumors. The head and face 
were every where exostosed, and as hard as marble. When 
the brain and soft parts were removed, the bones weighed in 
all more than eight pounds. The lower jaw alone weighed 
one pound, three ounces. The usual weight of an adult 
skull is one pound and nine ounces, showing an increased 
weight, in consequence of these exostoses, of six pounds, 
seven ounces. The patient had never complained of pain, either 
in his head or face. 

The symptoms of maxillary exostoses are very obscure. 
We have already seen that the disease may exist to an enor- 
mous extent without causing pain, the soft parts gradually 
thinning and distending before the pressure. When pain 
does exist, that symptom alone is not sufficient to convince 
us of the presence of exostoses. We have no certain sign 
but the peculiarly hard bony swelling. 

When the disease is accompanied by periostitis, which it 
is particularly liable to be when occasioned by syphilitic con- 
stitutional vitiation, the pain may be sufficiently acute. 

It is in cases such as these, that constitutional treatment 
has been found to arrest the deposition of bony matter, and 
the remedies most successfully used have been precisely such 
as are most efficient in constitutional lues. When no such 
taint exists, little can be done except to remove the tumor 
before its extent renders an operation difficult or impracti- 
cable. In many instances this has resulted in permanent 
relief. 



374 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

Fistula of the Superior Maxillary Bone. 

Bones seem, notwithstanding their density, to be capable of 
inflammation, and even of abscess. I have already mentioned 
caries as a kind of osseous ulceration, and there are many 
cases on record which seem to show that pus may be formed 
within a bone, distend its layers and ultimately perforate its 
structures and evacuate itself through a fistulous opening. 
Probably, in such cases, the suppuration is in the cellular 
tissue of the organ, rather than in the proper osseous tissues. 

Jourdain records ten cases of this character, of which I 
have selected the following : 

Case I. — A lady suffered with inflammation of the root of 
an upper first bicuspis on the right side, followed by alveo- 
lar abscess. After the inflammation had subsided, the tooth 
was removed ; but a fistulous opening still remained, emitting 
an ichorous discharge. After three months' endurance of 
this, the patient took advice, had the fistula cut out and 
dressed with balsam. It healed, and for five months seemed 
perfectly cured. But the bone again swelled on the site 
of the old disease, and now extended as far as the second 
molar, was very hard, and was attended with deep-seated 
pains: the gums were inflamed, and the tumor increased 
daily. 

Consultation was held, and opinions differed. Some 
thought it exostosis, others that the sinus was involved. The 
late M. Morand called me (Jourdain) into the case, and we 
concluded, upon careful examination, that by piercing a 
swollen spot in the gum just above the old fistula, we should 
come upon an opening into the interior of the bone. The 
introduction of an instrument to the depth of a line and a 
half caused a free discharge of sanguino-purulent matter, and 
the probe passed very freely into the cavity in the bone, the 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 375 

walls of which, above and below, seemed very firm. The 
socket of the extracted tooth had completely healed up. 

M. Morand was in favor of an incision through the bone 
for the purpose of excising the distended portion of bone, 
but with that unprejudiced liberality which always marks the 
man of true wisdom, he yielded to my arguments in favor of 
the cavity. I introduced the hot iron into the fistulous open- 
ing three times in eight days, following it up with suitable 
injections, which frequently brought away small fragments 
of bone from the interior of the cavity. The alveolus was 
soon reduced to its natural size, and in forty -three days the 
patient was perfectly cured. 

Case II. — Madame Massonet was referred to me by M. 
Moreau, of the Hotel Dieu, for a fistula above and between 
the first and second superior incisors. At the posterior part 
of the palatine arch there was a considerable tumor, without 
pain, softening, or change of color. From the summit of 
this tumor along the inner side of the alveolar ridge was a 
prominent line which seemed to mark the course of a fistu- 
lous canal from the external orifice to the tumor behind. 

No further cause could be assigned than the fact that some 
years previously, the patient had received a severe fall, 
from which time the second molar became painful and gra- 
dually loosened. I removed this tooth, but without any be- 
nefit to the tumor. The other teeth were sound. Injections 
and other means had been tried at the time of the appear- 
ance of the external fistula, but unsuccessfully. I regarded 
this case as one of true abscess of the bone. I ventured, M. 
Morand approving, to enlarge the external opening and 
make an incision through the entire palatine tumor, which 
discharged only blood. Suitable injections and gargles were 
used, but to no purpose. I then decided to lay open with a 
knife the whole course of the supposed canal above men- 
tioned, and touch it with mercurial water. On the third 



876 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

day, exfoliation of the parts thus touched exposed this canal. 
The subsequent treatment was very simple. The fistula was 
readily closed: and in six weeks the patient was sent home, 
perfectly restored. 

Case III. — Madam Boillard had a fistula on the anterior 
surface of the superior maxillary bone, the result of an alve- 
olar abscess of one of the incisors. Those teeth were so 
much worn away as scarcely to project above the gum, but 
were not at all carious. An operator, who was consulted, ex- 
tracted the second right incisor, which was immediately under 
the site of the abscess, and subsequently the first incisor of 
the same side, but without benefit. He then gave up the 
case, and the lady consulted me. 

I discovered by the introduction of the sound that the fis- 
tulous canal extended from the right second incisor in a tor- 
tuous direction, to the left canine, and as the two incisors on 
this side were very loose, I extracted them and found their 
sockets much softened. By destroying this softened bone, I 
established a free and direct communication for the escape 
of the purulent secretion of the fistulous canal. By medi- 
cated pledgets of lint I healed the parts. There was some 
exfoliation of the alveolar substance, and a cure speedily re- 
sulted. 

We see from this case, that caries is not the only cause of 
this disease. Irritation and inflammation of the dental pulp 
may occasion suppuration within the tooth cavity, which 
finding no vent in the direction of the crown, must escape at 
the extremity of the root, and may cause abscess, infiltration 
of the alveolar structure, and other grave injuries. In such 
cases a canal might be drilled through the crown, thus giving 
a direct escape for the matter, but if the suppuration have 
already extended to the alveolar socket, the extraction of the 
tooth is most advisable. {Extraction is always most advisable.) 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 377 

Case IY. M. Petit sent to me a boy, who for a year past 
had been troubled with a fistula just above the left nostril. 
It had come without any previous dental inflammation or 
tooth- ache, and had, therefore, been supposed by those who 
saw the case before me, to be consequent upon caries of the 
alveolus. A long and painful treatment based upon this 
diagnosis, served only to increase the ulcer. With my probe 
I could touch the root of the second incisor, which, however, 
had never given any pain or uneasiness. On pressing my 
probe up with some force, I gave vent to a considerable dis- 
charge of pus, yet there was no tumefaction of the gum nor 
loosening of the tooth. With some difficulty I prevailed 
upon the patient to allow the extraction of the tooth. This 
done, the pretended cancer healed in eight days. 

In this case there was evidently inflammation of the alveo- 
lar or exo-dental periosteum. 

Case Y. A person came to Paris for the relief of an affec- 
tion which resulted from alveolar abscess over the fangs of a 
decayed first molar of the right side. After the first .attack 
although the abscess discharged itself freely, a sensation re- 
mained in the cheek, as though there was a small stone there. 
The second attack, though attended by a free escape of pus, 
left the cheek hard and swollen, and the eye-lid much dis- 
tended with a peculiar clammy feeling in the region of the 
zygomatic and malar bones. I first saw the disease at this 
stage. 

On examining the mouth, I found a fistula between the 
gum and cheek, which penetrated the latter in a tortuous di- 
rection, and discharged an ichorous fluid. I removed the 
fangs of the first molar, but only blood followed the extrac- 
tion. 

On the fourth day, fluctuation was perceptible under the 
eye-lid, and on the sixth day, I made an incision then in the 
25 



378 DISEASES OF THE ANTKUM OE MAXILLAEY SINUS. 

direction of the fibres of the orbicularis muscle. As the swell- 
ing subsided, I used a compress bandage, taking care to keep 
open the incision till all deep-seated suppuration had ceased. 
The subsequent cure was attended with no difficulty. 

The student will find a number of other cases reported by 
Jourdain, whose work on the diseases and surgical operations 
of the mouth is a treasury of information upon these subjects. 
Though an old work, it is little known to the profession in 
this country, as it was not translated until the present year, 
(1851.) An excellent translation, enriched with a number of 
very just observations, was published by Messrs. Lindsay & 
Blakiston of Philadelphia. This translation is the work of 
a graduate of the Baltimore College of Dental Surgery ; a 
young gentleman of much promise, whose extreme modesty 
has not permitted; him to announce his name. The work 
should be in the hands of every surgeon, and surgeon dentist 
in the land. 

Ozena* 

This is a term applied to all those cases of fetid breath oc- 
casioned by inveterate ulcers of the primary air passages. 
These ulcers are sometimes seated in the antrum, sometimes 
in the nasal fossa, and are frequently connected with and owe 
their fetor to caries of the bones. They are, therefore, more 
common in syphilitic and scrofulous subjects. 

The breath of persons afflicted with ozena is often so offen- 
sive as to render them almost intolerable to others, and 
the consciousness of the disgust which their presence occa- 
sions, is naturally a source of continual mortification and dis- 
tress. 

Where the ulcer can be perceived and reached, it should 
be touched with the nitrate of silver, and the application re- 
peated until cure is effected. When no direct application 

* OC17, a stench. 



DISEASES OF THE ANTRUM OK MAXILLARY SINUS. 379 

can be made through the natural openings, as must be the 
case when the sore is seated in the antrum, an opening must 
be made as before directed, and a solution of nitrate of silver 
injected, if the caustic cannot be immediately applied to the 
part. 

If the patient be tainted with syphilitic disease, no local 
remedy can be effectual. He must be placed at once under 
proper constitutional treatment, and this must be persevered 
in until the vice be eradicated. In case of scrofula, the same 
remark applies. Local remedies, however, are not by any 
means to be neglected. They may very much hasten the 
cure, and perhaps may render effectual, constitutional means, 
which otherwise might be impotent. 

Every expedient should be tried before leaving the patient 
to suffer the distress and serious inconveniences attendant 
upon such a disgusting disease. 

Polypi and other Tumors. 

Polypi* are tumors of various consistencies and rapid 
growth, which appear in several cavities of the body which 
are lined by mucous membranes, but are most common in 
the nose, uterus and maxillary sinus. They also occur, occa- 
sionally, in the rectum and vagina. They appear much more 
frequently in the nose than elsewhere, and next to the nose 
in the uterus. 

The tumor growing into all the irregular cavities of the 
nasal fossa, &c, has sometimes an irregular form, which from 
a fancied resemblance to the animal of the same name, has 
originated its designation. 

Several varieties of polypoid tumors are described by 
writers. Mr. Pott thought one class of them always malig- 
nant, and another benign. The one, like carcinoma, being 

* TloAvg, many — nove, a foot. 



380 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

painful, causing constitutional irritation through morbid pro- 
cesses developed within itself, and tending to convert adjacent 
tissues into its own morbid structure, the other not painful, 
not causing any suffering, local or constitutional, except in- 
directly by producing pressure upon other parts or filling 
up cavities which are necessary to be kept open. In short, 
he considered that one class of polypi, the benign, are incon- 
venient or even fatal, merely by mechanical action; while 
the other, or malignant class, though equally troublesome by 
their pressure and obstruction which they cause, are per se 
pathologically dangerous to the health and life. 

Deschamps describes four varieties, which he calls vascular 
fungus, mucous lymphatic, scirrhous and sarcomatous. 

Dr. Warren classifies polypi as membranous, fibrous and 
vascular. The latter, he says, is rare. Jourdain recognises 
three kinds — one loose, pale, indolent and benign, also called 
vesicular polypus ; another, hard, unyielding, livid and pain- 
ful, marked with veins, and often hideous ; and a third, fleshy, 
elongated and easily stretched. 

Samuel Cooper observes, "Some polypi are red, soft and 
sensible, but free from pain, and exactly like a piece of heal- 
thy flesh. When this kind of polypus is of a softer consis- 
tence, semi-transparent, and of a pale, yellowish color in con- 
sequence of being less vascular, it is called the gelatinous 
polypus, and usually arises from the mucous membrane of 
the side of the antrum, or the middle of the cavity of the nos- 
tril between the upper and lower turbinated bone. No doubt 
carcinomatous tumors in the antrum have occasionally been 
confounded with polypi, but there is no good reason for be- 
lieving, as some have asserted, that true polypi never origi- 
nate in that cavity. Many eminent surgeons have testified 
to having met with true antral polypi. 

When a polypus of the benign kind occurs in the antrum, 
it may escape detection until it has completely filled the ca- 



DISEASES OF THE ANTKUM OK MAXILLAKY SINUS. 381 

vity and begun to push its way into the nose and distend the 
walls of the sinus. 

A tumor of the malignant kind might be suspected from 
the pain Seated in it, and when enlarged sufficiently to press 
upon the bones, the two-fold suffering produced by pressing 
and being pressed must cause greatly aggravated distress. 
The mechanical consequences of the continued pressure soon 
show themselves. The cheek swells, or rather is pushed 
out, the palate and alveolar ridge are depressed ; the molar 
teeth are loosened, the gums become inflamed and spongy, 
the floor of the orbit is elevated ; fistulous openings are often 
found through which sanious pus percolates, or the matter 
finds its way through the opening into the nose, and at length 
the tumor, pushing through the floor of the antrum, appears 
in the mouth, or forcing its way through one or both of the 
distended nasal openings is seen in one or both of the nos- 
trils. 

Of course, the parts subjected to this pressure and disrup- 
tion, become diseased, and inflammation, suppuration, ulcer- 
ation, caries and necrosis, may all be added to the list of 
secondary diseases incident to polypus. The causes of poly- 
pus are not satisfactorily ascertained. Probably they require 
some constitutional predisposition to render the parts where 
they appear capable of producing them, and when the sus- 
ceptibility exists, any irritation may be the exciting cause of 
the morbid growth. 

It is certain that diseased teeth and fangs must be regarded 
as the most common of the existing causes of polypus in the 
antrum. 

The following cases from Jourdain are in point : 

"In 1772, I had occasion to visit a shoemaker, living in 
the Faubourg St. Marcel, who had for some years had a kind 
of exostosis of the right superior maxillary. The tumor was 
as large as a medium -sized apple, displaced the nose, de- 



382 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

ranged the palate ; and threw the eye upward against the su- 
perciliary ridge, permitting the lids to open but slightly. 
The sinus had three fistulous openings : one below the malar 
process, a second near the bicuspids, and a third near the in- 
ner canthus of the eye. In none was there any discoloration 
of the skin, and alternately, from the first two, there was dis- 
charged an acrid reddish humor. Most of the teeth of the 
affected side were lost ; those which remained were sound, 
but much displaced by the tumor. The right nostril was ob- 
structed by a polypus of a scirrhous hardness. In sounding 
the sinus through the fistulous openings, the instrument came 
in contact with fleshy masses in that cavity, some hard, some 
soft, giving out, when wounded, a bloody discharge, re- 
sembling wine lees. The nasal wall of the sinus was de- 
stroyed, but the maxillary bone was not softened. 

"The disease seems to have had its origin in repeated at- 
tacks of alveolar abscess, the consequence of bad teeth, which 
usually terminated in fistula. Gradually the bone began to 
swell, and the nostril to become obstructed, till his appear- 
ance was such as I have described. Had I been suffered to 
operate, I would have removed all the teeth, good and bad, 
involved in the tumor, and then making a crucial incision 
through the cheek, would have exposed the bone, which, from 
its extreme thinness in this case, I might hope readily to re- 
move. I would then have removed the exposed tumors from 
the antrum, by knife, cautery, or both combined, as occasion 
might suggest; looking carefully to the condition of the bone, 
and seeking, after the operation, to establish a healthy sup- 
puration in the jf>art. 

"Case II. — Polypus in the Bight Sinus. — la 1773, a lady, 
whose right cheek had been swollen and singularly hard for 
nearly two years, applied to me. 

" The tumor was the result of successive inflammatory at- 
tacks of the first bicuspis and three molars of that side, only 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 383 

the fangs of which remained, and these were covered by a 
polypous tumor that had distended and softened the outer 
plate of the maxillary bone. 

"I first made an incision down to the alveolar sockets, and 
after the arrest of the hemorrhage, removed the roots, twelve 
in number, each having at their extremity a morbid growth, 
showing that here was the chief cause of the disease. Their 
removal caused considerable hemorrhage. I examined the 
wound on the next day, and found that the bulk of the tu- 
mor lay between the plate of tfie maxillary bone, diminish- 
ing upwards, and terminating at the orbit. 

"Between the cheek and gums were two fistulous openings, 
which discharged a dark, fetid humor. The diseased state 
of the bones decided me to remove the tumor by two verti- 
cal incisions through them. This space permitted me to in- 
troduce my finger into the sinus. Its membrane was swollen, 
and there was yet a portion of the tumor attached to the or- 
bital plate. This, from its propinquity to the eye, I feared 
to cauterize with the hot iron, and therefore used spirit of vi- 
triol, with a small quantity of corrosive sublimate dissolved 
in it, (nitrate of silver would be much better,) being careful 
to employ dry dressings, that the escharotic might not, by 
spreading, cause injury to the surrounding parts. 

"After eighteen days' use of the same, a healthy appear- 
ance of the membrane was induced, suppuration established, 
and at the close of the fourth month, after some slight exfo- 
liation of bone, the patient was restored." 

With regard to the treatment of antral polypi, it resolves 
itself simply into making an opening into the sinus, and re- 
moving the tumor. 

Unfortunately, many of these morbid growths recur after 
removal, and grow with more .rapidity than at first, and 
therefore it is necessary to destroy the mucous membrane 
upon which they are seated, so as perfectly to eradicate the 



384 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

disease. For this purpose, the old surgeons used the actual 
cautery freely. Probably the free application of lunar caus- 
tic would accomplish all that could be expected from 
the heated iron. It is often impossible to apply either 
so completely as to remove every particle of the diseased 
product ; and if the tumor be a result of constitutional pra- 
vity, we, for the most part, gain little by the operation. 

Dr. C. A. Harris thinks that in cases of malignant tumors 
seated in the antrum, the application of the white hot iron is 
indispensable to safety. 9 

In remarking upon the bold practice of the French sur- 
geons, in the treatment of these affections, Mr. Thomas Bell 
commends their mode of procedure as worthy of praise and 
imitation, and expresses himself very severely against the 
timidity of English surgeons, who have shrunk from the use 
of the actual cautery, and have left the patient to die with a 
lingering and painful disease, without any attempt at relief. 

Certainly, as life is rendered intolerable, and death inevi- 
table, by these tumors, we are justified in using any means 
which may promise relief. I have already, (chapter nineteen) 
described a malignant fungous tumor which occasionally 
makes its appearance in the antrum. When the disease is 
of the malignant character, a cure cannot be expected. 

The mode of amputating the superior maxillary, as de- 
scribed by Mr. Liston, has also been given in the nineteenth 
chapter. 

Insects in the Cavity. 

The human body has many parasites inhabiting its various 
tissues. More than a score of these have been described. 
Some infest the intestinal canal, others are found in the heart 
and large arteries ; some dwell in the muscular, others in the 
cellular tissue; some prefer the liver, others the kidneys, 
and some the sinuses of the head. 

The mode by which these creatures are produced, has long 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 385 

been a subject of curious inquiry, but it is not necessary for 
me to discuss the subject. It is enough to know that they 
exist within the body, and often prove troublesome inmates. 
That the larvae of insects do find their way into the maxillary 
sinus, is proved by abundant evidence. 

In the Memoirs of the Academy of Surgery, vol. v. p. 233, 
as quoted by Deschamps, it is recorded, that in the course 
of a disease of the maxillary sinus, there issued, from day to 
day, a considerable number of whitish worms, two or three 
lines long, some of which were living. The same author re- 
lates two instances in which long, round worms were found 
in the maxillary sinus. 

The most singular case of the kind is reported by Mr. Hey- 
sham, a medical practitioner of Carlisle, and may be found 
in Cooper's Surgical Dictionary. 

In this case, the patient was a strong woman of sixty, who 
was for many years subject to acute pain in the antrum, ex- 
tending over one side of the head. 

These pains never entirely ceased, but were more severe 
in winter than in summer, and were always subject to fre- 
quent periodical exacerbations. 

The patient had tried anodynes without advantage, and 
had submitted to a mercurial course, by which her sufferings 
were aggravated. All her teeth on the affected side had 
been drawn. At length it was determined to open the an- 
trum, though there was nothing to indicate abscess or any 
other disease in this cavity. 

In four days no benefit had resulted from the operation. 
Bark injections and the elixir of aloes were thrown into the 
sinus. On the fifth day a dead insect was extracted by means 
of forceps. It was more than an inch long, and thicker than 
a common quill. The patient now experienced relief for se- 
veral hours ; but the pains afterwards returned with the for- 
mer severity. Oil was then injected, and two other insects 



386 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

similar to the former were extracted. No others appeared, 
and the wound closed. She was much relieved for several 
months, when the pains returned worse than ever, and were 
particularly complained of in the frontal sinus. 

We are not informed of further treatment. 

Should worms be found in the cavity, they must be de- 
stroyed by the injection of oil or other liquids likely to ef- 
fect the purpose. 



CHAPTEE XXI. 



DISEASES OP THE PALATE. 



The palate is often incomplete through congenital defect. 
It is frequently the seat of disease, which destroys its soft 
parts, and even its bones. 

As the palate forms the vault or roof of the mouth, sepa- 
rating it from the nasal cavities, and furnishing a most impor- 
tant part of the organ of voice and mastication, its diseases 
and deficiencies are of great consequence, exceedingly im- 
pairing the comfort and usefulness of the subject of them. 

Congenital defects of the palate may differ very much in 
extent. Generally the deficiency is found along the median 
line, sometimes involving only the soft, sometimes also the 
bony structures. At times the fissure extends from the lips 
entirely along the median line of the roof of the mouth, pre- 
senting the appearance of the two lateral halves of the body 
not being united at this point. 

Congenital defects, however, are not always so regular. 
Errors of formation may occasion an increase of the con- 
cavity of the arch, forcing the alveolar ridges too far apart, 
and producing deformity in the dental range. Sometimes, 
from an opposite condition of things, the alveolar borders 
may be brought more than usually close together. The teeth 
may be imperfectly developed, and their texture less dense 
than usual. 

Mr. Stearns makes three classes of congenital fissure of 
the palate. The first class embraces all the cases in which 
the fissure extends through the velum, palate and maxillary 



388 DISEASES OF THE PALATE. 

bones, to the alveolar border, and sometimes through the 
whole extent of the median symphysis. This is usually com- 
plicated with hare-lip. 

In the second class, the bones of the palate are apparently 
entire, though the cavity of the arch may be somewhat 
greater than usual, and the fissure extend a short distance 
into their posterior margins. In this case, the lesion is al- 
most wholly confined to the velum palati. 

The third class embraces those cases in which the fissure 
is confined to the soft parts, extending, perhaps, only a short 
way up into the uvula. This form of fissure is, probably, less 
frequently met with than either of the preceding.* 

When the palate is defective, the voice is impaired, and the 
impairment is in proportion to the extent of the lesion. 
Sometimes it is almost entirely destroyed by the inability of 
the patient to utter distinct sounds. Nothing can be more 
distressing than this calamitous injury to the organs of speech, 
which combines the distress arising from the consciousness of 
ludicrous appearance with the inconvenience of difficult and 
imperfect articulation. 

Interference with the voice is not the only evil attending 
defects of the palate. Mastication and deglutition are also 
impeded. Food, notwithstanding the patient's careful or in- 
stinctive efforts, will find its way into the nose, causing great 
unpleasantness, and depriving the unfortunate subject of the 
deformity of much of the pleasure of eating, which, after all 
that has been said and written in its disparagement, is un- 
questionably the most universally prized of all sensual grati- 
fications. 

When the deficiency is congenital, the young infant finds 
difficulty in nursing, but generally, with that preservative in- 
stinct which is given to the little helpless creature, in such 

* Harris' Dictionary of Dental Science. 



DISEASES OF THE PALATE. 389 

perfection as to supply abundantly all lack of experience in 
such matters, the child generally contrives to manage its de- 
fective organs so well as to obviate much of the inconvenience 
naturally attending the deformity. Instead of taking the nip- 
ple between the upper surface of the tongue and superior 
gum, &c, the infant places the tongue on the nipple, and 
presses it against the lower gum, closing the palatine fissure 
with the tongue, as with an obturator.* 

The mechanism of nursing is perfected as the child ad- 
vances in life ; dexterity of course increasing with the con- 
stant use of the parts, until such a proficiency is acquired 
that solids are masticated, and speech is as far as possible per- 
formed. The mechanism of mastication as performed in such 
cases is then described by Delabarre. When the food is 
chewed, the aliment is conveyed between the tongue and 
movable floor which serves for a point d'appui to it, and then 
it is brought back between the teeth. Thus it is that the 
complicated operation of mastication and deglutition is per- 
formed without the alimentary morsel getting into the nose 
or if this does sometimes happen, it is the result of accident. 

When perforations of the palatine arch occur in mature life 
through the agency of disease, the patient is in a much more 
unfortunate case than the subject of congenital deformity. 
The latter, gradually habituated to the performance of masti- 
cation and deglutition with his imperfect organs, accom- 
plishes these functions, if not well, yet with comparative 
comfort, while the former having been habituated to use the 
tongue differently, is not capable of adopting the mode of pro- 
cedure applicable to his new condition, and consequently is 
continually passing his food and drink into his nose. If the 
teeth be not properly coapted, another source of difficulty and 
vexation is added, as the introduction of the food is thus ren- 
dered very troublesome. 

* Delabarre. 



390 DISEASES OF THE PALATE. 

If the velum and uvula be defective or wanting, degluti- 
tion is exceedingly difficult, as the alimentary matters, 
instead of passing comfortably along the pharynx, are, to a 
greater or less degree, forced into the posterior nares. This 
is the case whether the lesion be congenital or accidental. 
Sometimes deglutition can only be effected by throwing back 
the head as far as possible, and casting the food into the 
pharynx. 

The inconvenience of imperfect speech is as serious as that 
of incomplete or difficult mastication and deglutition. 

Mr. Stearns says, that perforation or fissure of the palate 
may render the articulation of some of the letters impossible, 
and at the same time vitiate the character of all the others. 
The indistinctness of utterance is usually proportioned to the 
extent of the lesion. Thus, when the fissure extends as far 
as the alveolar processes, the patient loses several of the let- 
ters, which another, with only a portion of the soft palate in- 
volved, is able to produce with considerable distinctness. 
In cases of fissure, particularly those of the more extensive 
kind, the movements of the tongue are comparatively limited, 
as the patient is instinctively aware that the very effort he 
should make in order to give letters their appropriate articu- 
lation, often serves to render the impediment more painful. 
So far, indeed, is this inactivity of the organs sometimes per- 
sisted in, that speech becomes little else than the emission of 
a succession of vowel sounds, which, in lieu of receiving pro- 
per consonant adjuncts, are only made intelligible by the ac- 
companying inflection, key, gesticulation and expression of 
countenance, all of which are, more or less, the vehicles of 
thought.* With the limited action of the tongue, nearly all 
the muscles concerned in the formation of articulate sounds, 

* Observations on Congenital Tissue of the Palate, with some Remarks on 
Articulation and Impediments of Speech, by Charles W. Stearns, Esq., Sur- 
geon, London. 



DISEASES OF THE PALATE. 391 

in a greater or less degree, participate, while the muscles 
about the nose, as the compressor nasi and depressor nasi, are 
violently contracted for the purpose of closing the nostrils 
and preventing the escape of the sound. This gives a par- 
ticularly disagreeable aspect to the features. 

The most common cause of lesions of the palate is syphilis. 
This terrible disorder, when it once becomes constitutional, 
produces a number of strange local affections, differing very 
much from one another, all of them distressing, and some of 
them dangerous, and not unfrequently fatal. 

Beginning as a local affection, usually a primary sore, 
syphilis may gradually poison the whole circulating fluids 
and cause defects of nutrition and alterations of tissue in va- 
rious parts of the body. 

The manner of effect produced by secondary syphilis, dif- 
fers very much in different persons, as it is influenced by a 
variety of determining or modelling circumstances. Erup- 
tions upon the surface, local inflammations, ulcers, augmen- 
tation and loss of parts, may all be occasioned by the pene- 
trating and potent virus. 

The soft parts about the throat are particularly apt to be 
the seat of constitutional syphilitic ulcers, and the bones of 
the palate are very frequently perforated or wasted by vene- 
real caries. 

It is very necessary, however, to be aware that palatine 
ulceration, caries and necrosis may occur from other than a 
venereal cause. It would be terrible indeed to add the cruel 
suspicion of such a malady to the sufferings of a patient 
whose disease, having no affinity to lues, should claim sympa- 
thy instead of begetting contempt and disgust. We must, 
therefore, be very careful to make no mistakes in matters of 
such delicacy. Moreover, the treatment of these affections must 
depend upon the accuracy of the diagnosis, and that which 



392 DISEASES OF THE PALATE. 

would be judicious in the case of syphilitic affection might 
be very improper under other circumstances. 

When the true history of the case can be obtained, the 
facts will give much assistance in forming an opinion, but 
this cannot always be procured ; we are, therefore, common- 
ly obliged to form our opinion from the appearances before 
us. 

The only constitutional vice, other than the venereal, 
which may cause a similar palatine devastation, is scrofula, 
and when scrofula is the cause of the affection, the preva- 
lent vice will display itself elsewhere, in derangements of 
the lymphatic system, and the other affections which usually 
attend upon this general pravity. 

Syphilis is more rapid than scrofula; and the local affec- 
tions produced by it are more painful. According to Mr. 
Hunter, venereal disease generally makes its appearance, in 
these parts, at once, in the form of an ulcer without much 
previous tumefaction. He describes the ulcer as a fair loss 
of substance, part being dug out as it were from the body of 
the tonsil (if seated upon it.) It has a determinate edge, and 
is commonly very foul, having a thick white matter like a 
slough, adhering to it, and not admitting of being washed 
away. All authors, however, admit the extreme difficulty 
of distinguishing venereal affections in these parts, with ab- 
solute certainty, by merely local observation, and no appear- 
ance of sores about the palate, warrant us in declaring the 
disease syphilitic, unless corresponding symptoms justify 
the suspicion. While this is the case, however, any suspi- 
cious sore will authorize us to try such remedies as are 
known to be efficacious in syphilis, it being much more dan. 
gerous to neglect a syphilitic sore than temporarily to mal- 
treat a scrofulous one. No purity on the part of a married 
female can always be satisfactory of her freedom from syphi- 
litic taint, as, disgraceful as it is to human nature to make 



DISEASES OF THE PALATE. 393 

the confession, we are frequently compelled to recognise the 
ravages of the disease in these victims to the matrimonial tie 
who are perfectly innocent of any impropriety. I need not 
say, that when the dentist discovers such a condition to exist, 
though humanity will demand that in some way or other the 
cure be provided, benevolence, no less imperious, requires, 
that the unfortunate subject of the odious inoculation shall 
be kept in blissful ignorance of the nature of the malady. 

Of course, where venereal or scrofulous disease is at work 
upon the parts, proper constitutional remedies must precede 
all mere mechanical attempts to repair existing damage. 

The devastation of the palatine tissues, soft or bony, may 
sometimes result from the local irritation produced by dead 
teeth, &c. This, of course, can only occur in those enfeebled 
constitutions in which nature is not able to resist even a 
trivial morbid impression, but seems barely capable of main- 
taining a nutrition equal to the ordinary wear and tear of 
tissues. 

That such cases do occur, is stated by Jourdain, Harris 
and many others. 

Harris says,* " The local irritants occasioning the palatine 
diseases are dead and loose teeth, roots of teeth, salivary calcu- 
lus, mechanical injuries, acrid humors, &c. The case of a 
lady of irreproachable character is related by Jourdain, in 
whom a scratch on the palate with a fish bone, caused a tu- 
mor, which suppurated and degenerated into an ulcer with 
hard elevated edges and a fungus in the middle." Dr. Cone 
mentions a similar case. 

The following are reported by Jourdain : 

Case I. — Mr. Noel had a tumor of the palate, which, on 
pressure, discharged pus through one fistulous opening on 
the outer side of the right alveolus, between the canine and 

* Dictionary of Dental Science, art. Palate. 

26 



894 DISEASES OF THE PALATE. 

incisor, and another in the socket of the second molar, which 
had been removed some time since. The patient would not 
consent to proper measures in the first instance. The canine 
incisors and first molar became loose, and were extracted : the 
alveolus around the site of the second molar sloughed away. 
The tumor still continued to enlarge, and some embarrass- 
ment was felt in the nostril : the patient then put himself un- 
der my care. The tumor, when lanced, discharged a very 
fetid pus, and I found, on introducing my probe, that a por- 
tion of the palate and maxillary bones were necrosed and 
almost completely detached. I removed them with ease : the 
one from the palate was the size of the nail of the index fin- 
ger, that from the maxilla, larger. The removal of these se- 
questra, exposed the pituitary membrane of the floor of the 
nostril, as was proved by the sneezing excited by touching 
it on the lingual side. I dressed the wound for some days 
with dry lint, and then used gargles, &c. In twelve days 
the cicatrix was complete. 

I have treated many similar cases, arising from simple ab- 
scess, the sequel of dental disease. I have always, when the 
opening was of sufficient size, either awaited the natural se- 
paration of the sequestrum, or when assured that it was no 
longer adherent to the second bone, gently withdrawn it. 
Simple causes may often be productive of extensive injury, 
as the following case will show : 

Case II. — A bailiff named Broch had a tumor of the pa- 
late as large as a pigeon's egg, with swelling of the nose and 
upper lip, consequent on a decayed condition of the teeth. 
Pus escaped from the nose, and there was a fistulous canal 
from the second incisor to the first molar of the left side. 

As the case seemed an urgent one, I removed the decayed 
teeth and stumps, thus destroying the fistula. I then excised 
the palatine tumors, found the bone carious and the nasal 
membrane covering it perforated, which accounted for the dis- 



DISEASES OF THE PALATE. 395 

charge of pus from the nostril. I first employed dressings of 
dry lint, emollient and detergent gargles, and after the subsi- 
dence of local inflammation, touched the bone with mercurial 
water twice in eight days. In this time the sequestrum se- 
parated, leaving an opening into the nostril about the size of a 
quill, which was closed by a prolongation of the mucous 
membrane. I made use of dressings of dry lint, gent]y ap- 
plied, and occasional styptics to suppress exuberant granu- 
lations. The entire cure occupied six weeks. 

For a great number of similar cases, the reader may con- 
sult Jourdain's work. 

When local irritants cause or seem to be connected with 
the disease, they should be promptly and completely removed. 
The after treatment will be conducted upon general surgical 
principles. 

When a fissure has been permanently formed and its li- 
mits ultimately defined, whether it has been congenital or 
accidental, the indication is to remove the deformity by pro- 
ducing a closure of the fissure, or, if this cannot be done, to 
supply the deficiency of the parts by such mechanical appli- 
ances as may be deemed most suitable. 

When the soft palate or some portion of it has been lost, 
the lesion has been substituted by means of an operation 
which has been termed staphyloplasty. * 

The operation can be successful only when the perforation 
is small. It consists in detaching a portion of mucous mem- 
brane from the surrounding parts, and so adjusting them with 
reference to the perforation as to procure a permanent cover- 
ing of the cavity, when adhesive inflammation has been ef- 
fected. The operation is difficult, and requires great dexte- 
rity in execution as well as ingenuity in contrivance. Dr. 
Pancoast, in his Operative Surgery, describes an operation of 

* 2raipv\r], the uvula, and nyaddw, I form. 



396 DISEASES OF THE PALATE. 

this kind, successfully performed by himself, to close a hole 
near the centre of the hard palate, which formed a communi- 
cation between the nose and mouth. 

The operation for closing a cleft palate is called staphylor- 
aphy.* It consists in paring away the edges of the fissure 
and closing them so perfectly as to produce union by adhesion. 

The operation has been successfully performed by a great 
number of surgeons, European and American, and several 
methods of performing it have been adopted and suggested; 
each having its advocates. 

Dr. S. P. Hullihen, surgeon dentist of Wheeling, Va., of 
whose surgical skill I have already made mention, had per- 
formed this operation successfully eleven times, up to the year 
1849. This ingenious surgeon has invented a bistoury for 
paring the edges of the fissure, which possesses decided advan- 
tages over the ordinary double-edged knife. It is composed 
of two parts, which open like scissors, but when closed, form 
a double-edged knife or bistoury. The manner of using it is as 
follows : after first seizing the cleft edge of the velum, at the 
base of the uvula, with a pair of curved forceps, and putting 
it on the stretch, the bistoury with its back towards and against 
the palate bone, should be pushed through the velum near 
its edge; then by opening it, the edges will be pared off in 
the most even and perfect manner possible. 

Further procedure should be suspended until the hemor- 
rhage, although seldom very great, shall have partially sub- 
sided. A needle armed with well waxed ligature, and held 
in a pair of suitable forceps, should be passed from before 
backwards through the most dependent part of the left margin, 
about three lines from the edge. As soon as it is seen on the 
opposite side, it should be grasped by the assistant, with a pair 
of long-handled forceps, and as soon as the hold of the port- 

* 2rct(pv?.rj, and F«<}»?, a suture. 



DISEASES OF THE PALATE. 397 

aiguille is relaxed, drawn through, replaced in the latter, and 
passed through from behind forwards, the right margin of the 
velum opposite to the left. After the patient has rested a 
few minutes, a second, third, or fourth ligature should be in- 
troduced.* 

Dr. J. C. Warren and his son, Dr. John Mason Warren, 
have each performed this operation repeatedly, and with great 
success. In most of these cases the fissure has extended 
through both soft and hard palate, and in one case through 
the jaw and lip. 

Dr. J. M. Warren's method has been to dissect off the mu- 
cous membrane from the hard palate, on either side, and stretch 
this across the fissure, and then unite the edges by sutures. 

Although it is generally asserted by surgical writers, that 
when the fissure of the hard palate exceeds an inch, no union 
can be expected, Dr. Warren has proved by his success in 
such cases, that the opinion is erroneous.f 

Dieffenbach recommends that a longitudinal incision be 
made at a short distance from the edges of the fissure, in order 
to permit the closure to be accomplished in the way before 
mentioned. 

A great variety of instruments has been invented by dif- 
ferent surgeons, and recommended to be used in this operation. 
I have already mentioned the cutting scissors of Dr. Hullihen. 
A variety of needles and needle-holders has been proposed. 
Dr. J. C. Warren uses a needle with a movable point. Dr. N. 
E. Smith prefers a simple lance-shaped instrument, mounted 
on a handle, and having a slit near its point, which opens at its 
posterior end. The needle is broader in front of the eye than 
behind it, which renders the passage of the back part easier. 
Armed with a ligature, the curved portion of the needle is car- 
ried beyond the fissure, and its point introduced behind the 

* Die. Dental Science. f Reese's Cooper's Surgical Dictionary. 



398 DISEASES OF THE PALATE. 

middle of the uvula, and as soon as it has come out far 
enough to expose the ligature in the slit, the ligature is taken 
hold of with a tenaculum, disengaged from the slit or eye in 
the needle, and the needle is withdrawn. A second ligature 
is introduced, half an inch higher up, and, if necessary, a 
third, at an equal distance from the second. With the ends 
of the ligature passed through the uvula, this part is drawn 
forward, until the fissure in the soft palate shall assume a 
nearly horizontal position. Its edges are then cut off with 
scissors or bistoury. The ligatures are then tied, and the 
ends cut ofF. 

Dr. Hullihen has invented an instrument for passing the 
needle, which he calls an acutenaculum, and which he thinks 
better adapted to the purpose than any other. It is com- 
posed of a staff and a slide. The staff is a small steel bar, 
six inches in length, a fourth of an inch in breadth, and an 
eighth of an inch thick, with an arm at the upper end, rising 
at a curve from the staff, and half an inch long. On the ex- 
ternal or superior side of this arm a duplicate arm is re- 
tained by a steel spring attachment, which brings the two 
arms in close contact, forming the jaws of the instrument. 
Between these two arms, and on the duplicature, is a small 
groove, formed to receive the ligature ; and when the ligature 
is pressed between the jaws of the instrument, they open, and 
it slides to the point designated for its reception, and immedi- 
ately below which, the jaws are perforated with a hole for 
the introduction of the needle. 

Two inches from the inferior end of the staff, a pair of 
rings are affixed to receive the thumb and index finger, the 
rings standing parallel with the staff, and sideways to the di- 
rection of the arms of the instrument. A slide formed of 
steel, equal in length, thickness and breadth to the staff, is 
made to fit the upper surface of the staff, and to move with 
ease up and down upon guides placed on the same. From 



DISEASES OF THE PALATE. 399 

the superior end of the slide is a short straight spear-shaped 
needle ; constructed with an eye just back of its point, with a 
small notch opening to it from the upper surface. 

When the ligature has been fitted in its place in the jaws 
of the instrument, and the slide adjusted to the staff, the slide 
is forced upwards, the needle and jaws approach each other, 
and the needle passes through the hole in the latter, just under 
the ligature, which is caught in the notch of the needle, and 
as the slide is drawn backwards the eye of the needle is 
threaded, and the ligature drawn through the velum. This 
instrument is certainly an ingenious one, and the prefer- 
ence given it by the inventor, who has operated so often and 
so well, is sufficient commendation. 

For a more particular description of this instrument, made 
intelligible by an accompanying plate, the reader is referred 
to an excellent article on cleft palate, by Dr. Hullihen, pub- 
lished in vol. v., page 166, of the American Journal of Den- 
tal Science. Concise and admirable directions will also be 
found in that paper, for conducting every step of the opera- 
tion. 

When the loss of parts is so great as to forbid an attempt 
to close the fissures by an operation, nothing remains to be 
done but to cover it by a gold plate or obturator, such as 
the circumstances of the case will admit. The skilful dentist 
will often be able to remedy these serious lesions to a very 
great extent, by well devised and artistically executed substi- 
tutes. 

For a description of these mechanical means, and the mode 
of adjusting them, I refer the reader to the works on mechani- 
cal dentistry. 



CHAPTEE XXII. 

ANESTHESIA. 

The suggestion of producing insensibility by narcotic in- 
halations so as to relieve patients from the pain of surgical 
operations; and render them easier of performance; was first 
made by a dentist; and the first use of the suggestion was in 
dental operations. 

Since that time, anaesthesia has become the glory of mo- 
dern surgery, and anaesthetic agents are among the regular 
and most carefully provided means of the general surgeon. 
Dentistry, however, which furnished the boon ; derives little 
benefit; and has suffered serious disadvantage from it. 

The agents used for general anaesthesia; are chloroform 
and sulphuric ether, and mixtures of these. 

Both these substances possess the power, through the in- 
halation of their vapour, to induce rapid stupor and pro- 
found insensibility, which may be perpetuated as long as 
the vapour is inhaled. The state of anaesthesia is a close ap- 
proximation to death. The patient under this condition has 
been boldly carried into the dark valley for the benevolent 
purpose of keeping him there until full vitality may be re- 
sumed without pain. To induce full anaesthesia is little less 
than using death for remedial purposes — inducing it par- 
tially and not to the extent of organic dissolution. 

Experience shows that this may be done with wonderful 
impunity in by far the greater number of cases. Though 
there be but a step between anaesthesia and death, yet it is 
a step that need very seldom be taken. The ground under 



ANAESTHESIA. 401 

the patient's feet is firm, and lie may walk safely to the verge 
of the precipice provided his guide be wise, and himself or- 
dinarily capable of endurance. But where the guide is ig- 
norant or imprudent, or the subject embarrassed by morbid 
conditions of the heart, lungs or brain, the danger is immi- 
nent, and a number of catastrophes, under such circum- 
stances, demonstrate the terrible nature of the power with 
which we dare to combat pain. 

Up to May, 1860, according to the tables of Dr. Kidd, 
(Med. Times and Gazette) 125 deaths from anaesthetics had 
occurred in Europe, and a considerable number in this coun- 
try. Considering that the administration of chloroform is 
now general in surgical, and quite common in obstetric prac- 
tice, the mortality attending its use is very small. 

But the most curious and important fact for dentists is, 
that the fatal cases have been in inverse proportion to the 
importance of the operation. Of eighty-five cases reported 
by Drs. Snow and Kidd, none occurred in "Eesections, large 
amputations, midwifery, ovariotomy, ligature of large ar- 
teries," &c, while ten were occasioned by anaesthesia for tooth 
drawing. In this country similar consequences have been 
observed, and dentistry has presented the largest share of 
victims. 

"When we consider that in the performance of great opera- 
tions, and particularly in obstetric cases, the anaesthesia is 
prolonged, while for dental and other minor operations it is 
evanescent, we may at first sight be much perplexed to ac- 
count for the anomaly. A little consideration, however, will 
remove the difficulty. 

In whatever manner chloroform acts to produce its effects, it 
is obvious that both the brain and heart are depressed in ac- 
tivity. In full anaesthesia the heart beats feebly, and conse- 
quently the brain is not supplied with its usual quantum of 
arterial blood. 



402 ANESTHESIA. 

In this condition the patient is liable to syncope or faint- 
ing. This is commonly not a dangerous condition, because 
in the ordinary state of the brain, heart and blood, reaction 
comes promptly on, and the suspension of circulation is but 
momentary. "When the patient is enfeebled by long or ex- 
hausting disease, or when the blood is impoverished, or the 
heart, or brain impaired, fainting is a serious and frequently 
a fatal occurrence. 

When one is under the influence of anaesthesia he is in a 
very bad condition for reacting in case he should faint, for 
the blood, heart, and brain, are all in an unnatural state, and 
little able to respond to the demand for healthful reaction. 
As I before observed, he has been brought to the verge of 
the precipice where he may safely stand, but a slight push 
will topple him over. Fainting is that push. 

Dr. Kidd says : " Of sixteen deaths under chloroform, where 
I was myself able to trace out the probable cause of the fa- 
tal issue, I found three where some remote disease of the 
heart might be suspected; but in thirteen, there had been 
probable, and in some, very serious, derangement of the ner- 
vous system — viz. : three deaths from delirium tremens and 
chloroform combined, two where chorea and meningitis were 
present, two from cysts in the brain, and four from other le- 
sions of cerebral tissue. It seems too evident, I think, that 
if syncope or 'fit' should occur in any such case, resuscita- 
tion is rendered difficult, as we have an imperfect brain and 
spinal apparatus to work with. Disease of the heart is a 
very rare cause of death from chloroform." 

Under any circumstances of the natural bodily condition, 
anaesthesia causes an "imperfect brain and spinal apparatus 
to work with," and should "syncope or fit occur, resuscita- 
tion is rendered difficult." In minor operations it has not 
been common to take the only precaution against syncope, 
by placing the patient in a recumbent position. Dentists place 



ANESTHESIA. 403 

him in a chair, and surgeons operating on the eye, on toe 
nails, fingers, &c, do the same. "When the patient sits down 
in the terrible chair he is often ready to faint with apprehen- 
sion ; a dose of chloroform rapidly brings down the action of 
the heart — syncope takes place nnder the worst possible com- 
bination of circumstances for reaction, and another victim is 
added to the list of those who have been destroyed by chlo- 
roform and carelessness. 

In dental operations it is necessary to produce very pro- 
found anaesthesia, because the part to be operated on is not 
accessible until the patient has become entirely unconscious, 
and because it is difficult to keep the inhalation during the 
operation. 

These observations account sufficiently for the anaesthetic 
calamities of dentistry. 

Ether is used by some surgeons, and especially by some 
dentists, because it is supposed to be less dangerous than 
chloroform. But there is no reason to believe that when 
anaesthesia is accomplished by ether the danger to the pa- 
tient is less than when the same condition results from chlo- 
roform. Three years ago nineteen deaths from ether were 
reported in Europe. 

When we consider that the extraction of teeth is not a 
dangerous operation; that the pain of it is not a bar to its 
being performed quite frequently enough ; and that the ad- 
ministration of anaesthetics in the dentist's chair is quite ha- 
zardous, common sense requires to abstain from the use of 
it in ordinary operations of the kind. Yet cases may occur 
where the morbid sensitiveness of the patient, or the pecu- 
liar difficulty or severity of the operation may authorize 
anaesthesia. In such cases the recumbent position is the only 
safe one. 

In view of the danger of general anaesthesia, much atten- 
tion and ingenuity have been directed to the possibility of 
procuring local insensibility. 



404 ANAESTHESIA. 

Congelation, galvanism, and topical narcotic applications, 
have all been suggested and experimented npon with more 
or less success. 

Congelation is effected by applying to the gum of the 
teeth to be extracted and the gums adjacent, a mixture of 
two parts of ice and one part of salt, and continuing the ap- 
plication until the surface of the gum is white and hard 
The pain of this application, which would require several 
minutes to effect its purpose, and the partial result that 
could be obtained, will probably prevent the general use of 
the suggestion. 

Galvanism was first applied for dental anaesthesia by Mr. 
Francis of Philadelphia, in 1858. A current of electro-gal- 
vanism is sent through the teeth via the forceps ; one con- 
ducting wire being attached to that instrument while the pa- 
tient holds the other. 

The result is sometimes quite successful. We saw it ap- 
plied in the case of a nervous female who had several teeth 
extracted with great satisfaction to herself. When, without 
her knowledge, the current was cut off, she immediately 
manifested great suffering. In other cases the relief was not 
as perfect, but in cases where there is great apprehension of 
pain the electric application may be made with advantage, 
as it is admirably calculated to impress the imagination and 
divert attention. It can do no harm, and unless too power- 
ful a current be used, causes little unpleasant sensation of 
the topical medications. Chloroform, either simple or mixed 
with other substances, is more or less used. 

By means of a cup fitting over the tooth and gum, a dos- 
sil of cotton, wet with ten or fifteen drops of chloroform, may 
be applied. It is said that insensibility of the parts can be 
thus produced in from seven to fifteen minutes. Dr. Taffc, of 
Ohio, recommends a mixture of tincture aconite, chloroform, 
alcohol and morphia. Probably the chloroform alone will 
accomplish all that the mixture can effect. 



INDEX 



A. ♦ 

Abscess, 75 

Absorption of sockets,..- 308 

Actual cautery, 107 

Affinity, chemical, 39 

Alveolar abscess, 95 

Amputation of lower jaw, 344 

Anasarca, 73 

Ansesthesia, 400 

Anatomy, 28 

Antiphlogistic remedies, 100 

Antrum, diseases of, 96, 354 

Arsenic, , , 173 

Aphthse, 89 

Appearance of gangrene, 115 

Aqua ammonite, 106 

Artery radial, 49 

Atmosphere, 82 

B. 

Blood, huffy coat of, 98 

Burns, , 276 

C. 

Callus, 281 

Cancrum oris, 110 

Cantharides,... . 106 

Caries, 39 



406 INDEX. 

Caries ofbone, , 83 

of teeth, 112 

of antrum...... 363 

Capillaries, affected by inflammation, 65 

Carcinoma, 131 

Causes of disease, 29 

in predisposing, exciting, specific, 30 

Character of inflammation, 83 

Chemosis, 72 

Cholera infantum, 209 

Cold, cause of disease, , 32, 34 

combats inflammation, 105 

Complication, . - 48 

Congestion, , 59 

Conjoint suppuration, 309 

Consequence of inflammation, 72 

Contagions, 36 

Contraction of lips, 317 

Contused wounds, 274 

i Convulsions, 211 

Counter- irritation, 105 

Croton oil, 106 

Crusta lactea, 214 

Cutaneous eruptions 212 

Cynanche, 88 

D. 

Dead teeth, productive of irritation, 93 

Death from extracting a tooth, 249 

Debility, 35 

Dentition. 

first symptom of, .. 198 

local diseases of, 202 

sympathetic, etc., 202 

second, — third, 216 

Diagnosis, 46 

Disease, definition of, 27 

symptoms and progress of, 43 

continuous, intermittent, 

remittent, chronic, acute, 44 

Diseases, general remarks on, 56 

Diseases, catalogue of, 59 

Dislocations, 285 

Dropsy of maxillary sinus, 355 

Dyspepsia, .... 179 

character of, 180 

cause of, 181 

treatment of, 183 



INDEX. 407 

E. 

Ear ache from teeth, 252 

Effects of morbid teeth on general system, 192 

Effects of diseased teeth and gums, 217 

Endemics 36 

Epidemics, 36 

Epilepsy, , 224 

Epulis, 288 

Erosion, 59 

Eruptions, syphilitic, 139 

Erysipelas, 86 

phlegmonous, 87 

Etiology, 28 

Exanthemata, influence, dental structure, 187 

Excitability, 35 

Exclusion, 48 

Exostosis, , 157 

of the teeth, 159 

of the antrum, 371 

Eye, affection of from teeth, , 228 

F. 

False membrane, 81 

Fever, 59 

Fever, inflammatory, idiopathic, symptomatic, 97 

Fibrine, 64 

Fibrine, effusion of, 81 

First dentition, morbid effects of, 195 

First intention, 270 

Fistula of the gums, 296 

Fistula, salivary, 338 

Fistula, 129 

Foreign bodies, 77 

Fractures, 279 

Friction, 108 

Fungi, 58 

Fungus hematodes, 133,152 

G. 

Gangrene, 59 

Gangrene, 114 

Gangrene, treatmentof, 115 

Gout, 307 

Gumboil, 78 

Gums, chronic influence of, 91, 111 

singular form of, 92 

treatment of 102 



408 INDEX. 

Gums, specific influence of, 108 

diseases of, 288 

spongy influence of, 297 

hemorrhage from, 299 

Gun shot wounds, 276 

H. 

Harelip 312 

Headache caused by teeth, 250, 251 

Health, 27 

Heat, 33 

Heat, inflammation, 71 

Hemorrhage, . 265 

I. 

Indurations, 59 

Gray, 60,82 

Inflammation, 59 

and its consequences,.. 61 

Healthy and unhealthy, , 62 

chronic, 83 

symptoms of, 84 

asthenic, 84 

treatment of, 99 

of antrum, 361 

Insects in Antral Cavity, 384 

Intermission, 45 

Intermittents, 45 

Intertrigo, 213 

Irritation, 85 

Issue, 106 

K. 
Kino, 104 

L. 

Lacerated wounds 272 

Leech bites, 104 

Leeching, 102 

Life, 27 

Ligature, 267 

Liquor Sanguinis, 65 

Lucifer Matches, 120 

M. 

Malaria, 37 

origin of, 38 



INDEX. 409 

Malic Acid, 41 

Maxillary Sinus, 95 

Maxillary, fracture of, 283 

Mechanical pressure, 108 

Melanotic production, 60 

Membrane false, 81 

Mercury, 108 

Mineral acids, 40 

Moisture, 105 

Mortification, 83, 114 

Moxa, „ 107 

N. 

Nature's Surgeon, 61, 82 

Nauseating Medicines, „ 101 

Nerves, inflamed, ... , 68 

Necrosis, 117, 83 

of the teeth, „ 119 

Neuralgia, , 163 

pain of, 69 

intermittent, 164, 168 

facial, 165 

Nitric ether, 41 

O. 

(Edema, 72 

(Edema of the glottis, 87 

Ophthalmia from abscess upon teeth, 251 

Osteo Sarcoma, 151 

Ozena, 97, 378 

P. 

Pain, , 53 

varieties of,. 54, 55 

inflammatior of, 67 

sympathetic, 69 

suppurative, 70 

Palate, diseases of, 387 

syphilis of, 391 

scrofula of, 392 

Parulis, 288, 293 

Pathology, '. 28 

Perforation, 59 

Phlegmon, 85 

Phlyctense, 275 

Phthisis induced by dental irritation, 241, 243 

Physiology, 27 

Poisons, aerial, 37 

27 



410 INDEX. 

Polypi, ....... 15, 259 

Pulse, 49 

Pulse, directions for feeling,. , 52 

Pus, 73 

Pustules, .. 59 

Punctured wounds, . 274 



Quinine in Neuralgia, . 171 

Quotidian, — 45 

R. 

Ranula,.. 322 

Redness, inflammatory,... , 70 

Regimen, 57 

Remedies, 57 

Resolution,.. 72 

Rheumatism of the Jaw, 307 

Rubefacients, 105 

S. 

Salivary calculus, 101 

Salivation, mercurial, .... ......... 108 

Salivation, treatment of, ,. 110 

Salivary tumors, . 322 

Saliva acid, 175 

Scarification, 102 

Scurvy, Ill 

Secretions of mouth, 174 

Sensation of inflammation...... 68 

Seton, 106 

Sequestrum, 114 

Sinus, „ . 86 

Softening of the antrum, 370 

Spasm, pain of, , 69 

Specifics, 57 

Sphacelus,.. 114 

Stomatitis, ... 88 

Stomatitis, ulcerative, ., 90 

Strophulus 214 

Styptics, 266 

Suppuration, .' 59, 73 

Suppuration, pain of, 70 

Suppurants, , 116 

Suppuration of antrum, 362 

Sutures, 271 

Syphilis, Ill 



INDEX. 411 

U. 

Ulceration, 59 

Ulceration, 78 

phagedenic, 81 

Ulcers, 121 

causes of, 122 

classification of, 123 

simple purulent, 123 

simple vitiated, 124 

callous 126 

fungous, , 127 

sinuous, , 128 

carious, , 130 

cancerous,.. 131 

venereal, 136 

scorbutic, 141 

scrofulous, 143 

V. 

Veins, stuffing or engorgement of, 59 

Vegetations, 59 

Vesicles, 59 

Vesication, 73 

Vesicants, 106 

Venereal affections of the bones, 138 




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